A phase IB/II study of nivolumab in combination with eribulin in HER2-negative metastatic breast cancer (KCSG BR18-16)

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Background: Combining immune checkpoint inhibitors with chemotherapy has become a promising therapeutic strategy in metastatic breast cancer. Eribulin is a potent microtubule inhibitor and modulates the immune microenvironment of tumor cells. Therefore, combining eribulin to nivolumab may synergize antitumor efficacy in metastatic breast cancer. Methods: Adult patients with histologically confirmed recurrent/metastatic HER2- breast cancer were enrolled prospectively from 10 academic hospitals in Korea (ClinicalTrials.gov Identifier: NCT04061863). Key eligibility criteria included prior treatment with taxanes and/or anthracyclines, ≥1 measurable disease, and ≤2 prior cytotoxic chemotherapies in the metastatic setting. Patients received nivolumab 200 mg intravenously (IV) on day 1 plus eribulin 1.4 mg/m2 IV on day 1 and 8 of every 3 weeks until disease progression or intolerable toxicity. The dose level was determined from safety profile of three patients in run-in phase. The primary endpoint was investigator-assessed progression-free survival (PFS) rate at 6 months. Secondary endpoints included investigator-assessed objective response rate (ORR) per RECIST v1.1, disease control rate (DCR), overall survival (OS), and toxicity profile of the combination treatment. The association between PD-L1 expression by SP142 Ab and efficacy was analyzed. Results: From August 2019 to June 2021, 90 patients (HR+HER2- 45 pts/TNBC 45 pts), with a median age of 51 (range 31–71), were enrolled in the study. With a median study follow-up time of 16.3 months, 68 (75.6%) patients experienced progressive disease. PFS rate at 6-months was 49.6% and 24.1% in patients with HR+HER2- and TNBC group, respectively. Median PFS was 5.6 months (95% CI: 4.3-6.8) and 3.0 months (95% CI: 1.3-4.7) for HR+HER2- and TNBC group, respectively. ORRs were 53.3% (CR:0, PR: 24) for HR+HER2- and 21.8% (CR1, PR: 12) for TNBC. Patients with PD-L1+ tumors (PD-L1 expression ≥ 1% on TC or IC) had similar ORR compared to PD-L1- tumors (ORR 50% vs. 53.8% in HR+HER2-, 30.8% vs. 29.0% in TNBC). The most common grade 3/4 adverse event was neutropenia (15/90, 16.7%), and the most common immune-related adverse events were grade 1/2 hypothyroidism (19/90, 21.1%) and grade 1/2 pruritus (16/90, 17.8%). Five patients had discontinued study treatment due to immune-related adverse events (3 pneumonitis, 1 hepatitis, 1 skin rash). Conclusions: In this parallel phase II clinical trial, the addition of nivolumab to eribulin showed promising efficacy and tolerable safety profile in previously treated HER2- MBC. Further survival and exploratory analyses to find predictive markers will be followed. Clinical trial information: NCT04061863. [Table: see text]

Infectivity of Coronavirus Disease 2019: A Prospective Cohort Study in the Korean Metropolitan Area

BACKGROUND

Although several characteristics of coronavirus disease 2019 (COVID-19), an ongoing pandemic disease, have been identified, data on the infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are limited.

METHODS

This prospective cohort study was conducted to analyze the infectivity of SARS-CoV-2 based on data of all patients diagnosed with COVID-19 confirmed using real-time polymerase chain reaction test from January to April 2020 in Gyeonggi-do, the largest province in Korea.

RESULTS

Of the 502 patients, 298 consisting of 106 clusters with 5,909 contacts were included. Of these, 277 (93.0%) were symptomatic, and the most common symptoms were cough, fever, sputum, sore throat, and headache. A total of 94 patients (31.5%) had pneumonia, while 8 (2.7%) died during the follow-up period. The secondary attack rate (SAR) in the study population was 3.5% (204/5,909). In exposure settings, the SAR was higher in religious gathering (13.5% [95% confidence interval, 10.7-16.8%]), workplaces (8.49% [95% CI, 6.08-11.74%]), and schools (6.38% [95% CI, 3.39-11.69%]) than in health care facilities (1.92% [95% CI, 1.45-2.55%]). Sore throat at any period, dyspnea at diagnosis or any period, lower cycle threshold value in the lower respiratory tract samples, leukocytosis, and higher bilirubin levels were associated with higher infectivity of COVID-19. The presence of symptoms was not related to the infectivity.

CONCLUSION

In establishing the infection control strategies for COVID-19, the variables associated with high infectivity may be considered.

Comparative Clinical and Radiographic Cohort Study: Uniportal Thoracic Endoscopic Laminotomy With Bilateral Decompression by Using the 1-Block Resection Technique and Thoracic Open Laminotomy With Bilateral Decompression for Thoracic Ossified Ligamentum Flavum

BACKGROUND

Symptomatic thoracic myelopathy secondary to thoracic ossified ligamentum flavum (OLF) often requires decompression spinal surgery.

OBJECTIVE

To compare clinical and radiological outcomes in uniportal endoscopic vs open thoracic decompression for thoracic OLF.

METHODS

Retrospective evaluation of patients who underwent uniportal thoracic endoscopic unilateral laminotomy with bilateral decompression (TE-ULBD) by using the one-block resection technique compared with thoracic open laminotomy (TOL) with bilateral decompression. Radiological outcomes in MRI scan and clinical charts were evaluated.

RESULTS

Thirty-five levels of TE-ULBD were compared with 24 levels of TOL. The overall complication rate of TOL was 15% while TE-ULBD was 6.5%. Both TOL and TE-ULBD cohort had significantly improved their visual analog scale (VAS), Oswestry Disability Index, and Japanese Orthopaedic Association (JOA) myelopathy score after operation. Comparative analysis of TE-ULBD performed statistically and significantly better than TOL in improvement of final VAS and JOA scores. The mean difference ± standard deviation of VAS and JOA improvement in final follow-up when compared with preoperative state of TE-ULBD and TOL was 0.717 ± 0.131 and 1.03 ± 0.2, respectively, P < .05. The mean Hirabayashi recovery rates were 94.5% (TE-ULBD) and 56.8% (TOL). There was no statistical difference in change in preoperative and final Oswestry Disability Index and MRI volume at upper endplate, middisk, and lower endplate canal cross-sectional area.

CONCLUSION

Uniportal TE-ULBD achieved significantly improved pain and neurological recovery with sufficient spinal canal decompression, as compared with thoracic open laminectomy for patients with myelopathy secondary to OLF in our cohort.

Continuing perioperative estrogen therapy does not increase venous thromboembolic events in transgender patients: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to compare the risk of venous thromboembolic events (VTE) between patients suspending and continuing estrogen therapy perioperatively, in male to female gender-affirming surgery (vaginoplasty).

MATERIALS AND METHODS

The authors conducted a systematic review and meta-analysis of existing research on male to female gender-affirming study, which compared the risk of VTE among the usage of estrogen perioperatively.

RESULTS

A total of 209 studies were identified as potentially eligible among PubMed, Embase, and Cochrane library databases. Among the studies, 191 studies were excluded due to their abstract inappropriateness. Out of the remaining 18 studies, only 3 articles were eligible and were finally included. Meta-analysis was performed and showed odds ratio of 0.77 (95% CI: 0.04, 14.01).

CONCLUSIONS

Perioperative estrogen therapy does not increase VTE risk on male to female gender-affirming surgery. Therefore, estrogen therapy may be continued perioperatively in vaginoplasty. More prospective studies are needed.

Comparison between Wound Closure Methods in the Reversal of Diverting Ileostomy

Background/Aims

The objective of this study was to determine the more appropriate wound-closure method by comparing the effectiveness of two methods in a group of patients who underwent ileostomy repair.

Methods

The study conducted after obtaining the approval of the Institutional Review Board (IRB) included 58 patients ≥19 years of age who underwent ileostomy at the Department of Surgery at the Presbyterian Medical Center. This was a retrospective, single-center trial. Patients who underwent ileostomy closure between January 2011 and September 2017 were assigned to the primary wound-closure (PC, n=25) group and the purse-string wound-closure (PSC, n=33) group. Post-repair complications, such as wound infection, delayed healing, and patient satisfaction related to wound management, were investigated and compared according to the wound-closure method.

Results

The PSC group had a significantly lower surgical site infection rate than the PC group (0% vs. 44%, p<0.001). The wound-healing period was also significantly different between the PC and PSC groups (mean 27.18 days vs. 20.96 days, p=0.023). However, the postoperative wound-healing delay of >30 days was not significantly different (39% vs. 20%, p=0.114). In addition, there were no significant differences in the response to questionnaires on patient satisfaction between the two groups.

Conclusions

PSC has a lower surgical site infection rate and the wound-healing delay was not very different from that of PC. Therefore, if patients are at risk of wound infection, such as in severe wound contamination, long operating time, and immunocompromised conditions, we should consider PSC as a wound closure method of choice.

The R3-Type MYB Transcription Factor BrMYBL2.1 Negatively Regulates Anthocyanin Biosynthesis in Chinese Cabbage (Brassica rapa L.) by Repressing MYB-bHLH-WD40 Complex Activity

Chinese cabbage (Brassica rapa L.) leaves are purple in color due to anthocyanin accumulation and have nutritional and aesthetic value, as well as antioxidant properties. Here, we identified the R3 MYB transcription factor BrMYBL2.1 as a key negative regulator of anthocyanin biosynthesis. A Chinese cabbage cultivar with green leaves harbored a functional BrMYBL2.1 protein, designated BrMYBL2.1-G, with transcriptional repressor activity of anthocyanin biosynthetic genes. By contrast, BrMYBL2.1 from a Chinese cabbage cultivar with purple leaves carried a poly(A) insertion in the third exon of the gene, resulting in the insertion of multiple lysine residues in the predicted protein, designated BrMYBL2.1-P. Although both BrMYBL2.1 variants localized to the nucleus, only BrMYBL2.1-G interacted with its cognate partner BrTT8. Transient infiltration assays in tobacco leaves revealed that BrMYBL2.1-G, but not BrMYBL2.1-P, actively represses pigment accumulation by inhibiting the transcription of anthocyanin biosynthetic genes. Transient promoter activation assay in Arabidopsis protoplasts verified that BrMYBL2.1-G, but not BrMYBL2.1-P, can repress transcriptional activation of BrCHS and BrDFR, which was activated by co-expression with BrPAP1 and BrTT8. We determined that BrMYBL2.1-P may be more prone to degradation than BrMYBL2.1-G via ubiquitination. Taken together, these results demonstrate that BrMYBL2.1-G blocks the activity of the MBW complex and thus represses anthocyanin biosynthesis, whereas the variant BrMYBL2.1-P from purple Chinese cabbage cannot, thus leading to higher anthocyanin accumulation.

Abstract P3-13-08: Fusion analysis including NTRK fusion in breast cancers (BC): From RNASeq data analysis from 629 BC tissue samples

Background: Neutrotrophin receptor tyrosine kinase (NTRK) gene fusions (NTRK1, NTRK2, or NTRK3) are oncogenic drivers of various tumor types. The NTRK fusion was detected in less than 5% of breast, colorectal, lung or any other types of cancers. However, large scaled next generation sequencing data for NTRK fusion in breast cancer have not existed. In this study, we performed RNASeq and fusion analysis including NTRK genes. Methods: We prospectively collected BC tumor tissues from the translational research conducted in Samsung Medical Center. Fusion was predicted from RNAseq using the following seven softwares(SWs): ChimeraScan, DeFuse, MapSplice, TophatFusion, STAR.Arriba, STAR.fusion, and STAR.SEQR. To remove false-positive fusion calls, calls less than 3 left/right spanning reads and 10 total supporting reads were removed. After filtering out the blacklist fusion calls which were recurrently detected, calls commonly predicted in more than two SWs were analyzed. Results: In total 629 BC samples, 613 samples were finally analyzed after quality control (QC) of RNASeq. According to immunohistochemistry (IHC) profile, 356(58.7%) was hormone receptor (HR) positive human epidermal growth factor receptor 2 (HER2) negative BC, 42 (6.9%) of HR positive HER2 positive BC, 53 (8.7%) of HR negative, HER2 positive and 155(25.6%) of triple negative BC (TNBC). PAM50 prediction informed that 174(28.9%) of luminal A, 151(24.6%) of luminal B, 170 (27.7%) of basal-like, 85 (13.9%) of HER2-enriched and 33 (5.4%) of normal. In median number of fusion events, 12 was called by ChimeraScan (Interquartile range [IQR]: 5, 33), 57 by DeFuse (IQR: 33, 82), eight by Mapsplice (IQR: 5, 12), two by TophatFusion (IQR: 0, 4), five by STAR.Arriba (IQR: 2, 12), two by STAR.fusion (IQR:0, 5) and three by STAR.SEQR fusion caller (IQR: 1, 7) after call filtering. After initial fusion call, we excluded the results from ChimeraScan and DeFuse fusion callers because of discrepancy of number of called fusion events. In five fusion callers, median number of fusion events was eight (IQR :2,20) per BC sample. In terms of NTRK fusion, we detected NTRK2-BANCR fusion event in one TNBC patients (1/425, 0.2%). This fusion was detected in four of five SWs for fusion detection with significant number of supporting reads in RNASeq. NTRK2-BANCR fusion was the out-of-frame fusion, which C-terminal truncated protein kinase domain of NTRK2 and its partner long non-coding RNA BANCR was combined and RNA expression of this fusion was increased. Other fusion events of BCs were NCOR2-PARP4 (3.7%), BRD4-NWD1 (3.7%), ESR1-RGS17 (1.8%), FGFR1-TACC1 (0.2%) and MKRN1-BRAF (0.2%). In BC subtype according to IHC, fusion events were more frequently observed in TNBC compared with other subtypes regardless of the type of fusion filters. In terms of intrinsic subtype, fusion events were most frequently observed in basal like type and least in normal like intrinsic subtype (all ps&lt;0.05, respectively). Conclusions: In this large scaled RNASeq data analysis, a few fusion events were observed in BC patients. Prevalence of NTRK was extremely rare. Additional investigation including functional validation would be followed.

Citation Format: Ji-Yeon Kim, Kyunghee Park, Woong-Yang Park, Jeong Eon Lee, Seok Won Kim, Seok Jin Nam, Jonghan Yu, Young-Hyuck Im, Jin Seok Ahn, Yeon Hee Park. Fusion analysis including NTRK fusion in breast cancers (BC): From RNASeq data analysis from 629 BC tissue samples [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-13-08.

Abstract P1-08-07: Prediction model of the response of neoadjuvant chemotherapy and long term survival according to multi-omic profiling in cooperation with clinicopathologic features in patients with breast cancer

Background: The advance of next generation sequencing (NGS) leads to give the abundant genetic information of breast cancer (BC). We developed the prediction model of neoadjuvant chemotherapy (NAC) response and long term survival using genetic characteristics in cooperation with clinicpathologic features. Methods: Early and locally advanced BCs which would be planned to receive standard NAC (four cycles of anthracycline plus cyclophosphamide and four cycles of docetaxel or docetaxel plus trastuzumab for human epidermal growth factor receptor 2[HER2+] disease) followed by curative surgery. We prospectively collected tumor tissue and matched blood three times for each patients: at BC diagnosis (T1), three weeks after the first cycle of NAC (T2), and curative surgery (T3). Whole exome sequencing (WES) and RNASeq were performed to detect somatic mutation, mutational signature, tumor mutational burden (TMB) and PAM50 prediction was to classify intrinsic subtype. In terms of clinical variables, clinical stage and IHC subtype at diagnosis, pathologic complete response (pCR), residual cancer burden (RCB) class and distant recurrence free survival (DRFS) were used for prediction model development. Logistic regression was used for predicting RCB class and pCR with clinical and genomic variables at T1. Univariate and multivariate Cox regression were performed to identify prognostic factors for DRFS. Results: In total, 210 patients who were treated with scheduled NAC were enrolled. Finally, WES in 252 BC tissues (T1:123, T2:106 and T3:23) RNASeq in 198 BC tissues (T1:100, T2:77 and T3:21) were conducted from 123 patients. In NAC response, 52 patients achieved pCR(42.3%) and 14 patients were in RCB class 3, 39 in class 2, 14 in class 1 and 51 in class 0. Median follow up duration was 44months and distant recurrence was observed in 13 patients. TP53 mutation (60%) was the most commonly detected genetic alteration followed by TTN(31%), ERBB2(25%) and PIK3CA(18%). Eight BCL11A (3%) and 3 MPL mutations (1%) were also observed respectively. Serial tumor sequencing suggested that mutation profile have not changed during NAC. In terms of mutational signature, signature 3 was most frequently observed and no difference was observed in serial sequencing data. In addition, APOBEC (sig.2) and HRD (sig.3) were observed differently according to intrinsic subtype. In terms of intrinsic subtype, basal subtype decreased during NAC and luminal A type increased. Median TMB was 87 (range, 14-570). In prediction model, clinical N3(cN3) stage (Odds ratio [OR] of cN3 vs. not : 4.536, 95% confidence interval [CI]: 0.925, 44.016, p=0.042) and intrinsic subtype at BC diagnosis (OR of non-luminal vs. luminal types: 0.208, 95% CI: 0.062, 0.604, p=0.001) were associated with pCR. Clinical stage (OR of clinical stage III vs. II: 4.115, 95% CI: 1.094, 19.217, p=0.021), TMB (OR of TMB high vs. low: 0.255, 95% CI: 0.043,1.042, p.value=0.045), MPL genetic alteration (OR of mutation vs. wild type: 16.347, 95% CI: 0.797,1013.88, p.value=0.037), BCL11A (OR of mutation vs. wild type: 16.347, 95% CI: 0.797,1013.88, p.value=0.037) were associated with RCB class (3 vs. others). In terms of DRFS, prediction model consisted of clinical stage (Hazard ratio [HR] of stage III vs. II: 3.496, 95% confidence interval [CI]:1.337, 5.654), PIK3CA (HR of mutation vs. wild type: 1.572, 95% CI:-0.008, 3.152) TMB (HR of high vs. low: -1.999. 95% CI:-3.669, -0.329) had c-index of 0.861(95% CI:0.805, 0.916). Conclusions: During NAC, somatic mutation and mutation signature were consistently maintained while intrinsic subtype dynamically changed. In prediction model, TMB, PIK3CA mutation and clinical stage showed predictive roles on DRFS of BC in NAC setting.

Citation Format: Ji-Yeon Kim, Kyunghee Park, Woong-Yang Park, Jeong Eon Lee, Seok Won Kim, Seok Jin Nam, Se Kyung Lee, Zhengyan Kan, Yeon Hee Park. Prediction model of the response of neoadjuvant chemotherapy and long term survival according to multi-omic profiling in cooperation with clinicopathologic features in patients with breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-08-07.

Abstract PD2-08: Serial genomic profiling reveals molecular mechanisms of breast cancer resistance to palbociclib

CDK4/6 inhibitors such as palbociclib in combination with endocrine therapy (ET) have remarkablyimproved the outcome of patients with ER+/HER2- metastatic breast cancer (MBC). However, manypatients are intrinsically resistant to CDK4/6i therapy, and those who respond eventually acquireresistance. Although high baseline CCNE1 expression and rare alterations in RB1 and FAT1 geneshave been shown to be associated with CDK4/6i resistance, the molecular mechanisms of CDK4/6iresistance are complex and remain poorly understood. To better understand and overcome CDK4/6iresistance, we performed multi-omics profiling of paired tumor biopsies from ER+/HER2- MBCpatients treated with palbociclib combined with ET. Tumor biopsies taken at pre-treatment, on-treatment, and progressive disease (PD) from 71 patients were profiled using whole-exomesequencing (WES), whole-transcriptome sequencing (RNA-Seq) and IHC analysis. Ourcomprehensive analysis identified several tumor intrinsic molecular markers associated with worsePFS, including the Luminal B subtype (p=0.012, HR=2.593), BRCA1/2 pathogenic mutation (p=0.012,HR=2.67) and mutation signatures linked to APOBEC enzymatic activity (p=0.002, HR=3.19).Conversely, the estrogen response signature (p=0.006, HR=0.43) was associated with favorableprognosis. Unsupervised analysis revealed a cluster of tumors enriched in homologousrecombination deficiency (HRD) linked genomic scars that was associated with poor prognosis(p=0.005, HR=2.49). Of note, these HRD-high tumors responded even more poorly to treatment whenco-occurring with TP53 somatic mutations. Integrative analysis further identified three poorprognosis clusters (IC2-4) enriched in Luminal B, proliferative and HRD features when compared tothe favorable prognosis cluster (IC1).Comparing baseline vs. PD samples, we observed a pattern of post-treatment enrichment for the poorprognosis markers. In addition, breast cancer-associated genes such as BRCA1/2, TP53 and PTENharbored a higher prevalence of genomic alterations including somatic mutation, amplification,. deletion and gene fusion at PD. Cell cycle gene expression and signatures also markedly increased atPD compared to baseline whereas estrogen response signatures decreased. Upon diseaseprogression, tumors had frequently switched to molecular subtypes with aggressive and estrogenindependent characteristics, demonstrating high plasticity in response to CDK4/6i and ET treatment.These patterns of acquired resistance were validated by IHC analysis of cyclins E1 and E2, Ki67 andpRb. To investigate the genomic alterations responsible for acquired resistance, we compared 21paired baseline and PD samples. We observed that PD-specific RB1 loss-of-function events occurredwith higher prevalence than previously reported, underscoring a major role of cell cycle de-regulation in conferring resistance to CDK4/6 inhibition. In this prospective longitudinal multi-omicsstudy, we identified novel candidate biomarkers that can be used to improve prediction of responseto CDK4/6i. In addition, we derived new insights into the molecular mechanisms of drug resistanceto palbociclib plus ET that will help guide therapeutic strategies and drug development inHR+/HER2− MBC.

Citation Format: Zhengyan Kan, Seock-Ah Im, Kyunghee Park, Ji Wen, Kyung-Hun Lee, Yoon-La Choi, Won-Chul Lee, Ahrum Min, Vinicius Bonato, Seri Park, Sripad Ram, Dae-Won Lee, Ji-Yeon Kim, Su Kyeong Lee, Won-Woo Lee, Jisook Lee, Miso Kim, Scott L. Weinrich, Han Suk Ryu, Tae Yong Kim, Stephen Dann, Diane Fernandez, Jiwon Koh, Song Yi Park, Shibing Deng, Eric Powell, Rupesh Kanchi Ravi, Jadwiga Bienkowska, Paul A. Rejto, Woong-Yang Park, Yeon Hee Park. Serial genomic profiling reveals molecular mechanisms of breast cancer resistance to palbociclib [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD2-08.

Real-World Evidence of Trastuzumab, Pertuzumab, and Docetaxel Combination as a First-Line Treatment for Korean Patients with HER2-Positive Metastatic Breast Cancer

Purpose

Trastuzumab has markedly improved the survival outcomes of patients with human epidermal growth factor receptor 2 (HER2)–positive breast cancer, and dual blockade of HER2 using trastuzumab and pertuzumab in combination with taxanes (THP) has become a standard of care for HER2-positive metastatic breast cancer (MBC) worldwide since the CLEOPATRA trial. We assessed the outcomes of THP as a first-line treatment for Korean HER2-positive MBC patients in the real-world setting.

Materials and Methods

Between August 2008 and October 2020, we identified 228 HER2-positive MBC patients who received THP as a first-line palliative chemotherapy. We analyzed survival outcomes, efficacy, and adverse events of THP retrospectively.

Results

After a median follow-up duration of 28.7 months, median overall survival and progression-free survival were 58.3 months (95% confidence interval [CI], 36.6 to 80.0) and 19.1 months (95% CI, 16.2 to 21.9), respectively. Better survival outcomes were observed in patient who received docetaxel for more than six cycles. Patients exposed to anti-HER2 directed therapies in a perioperative setting had poor survival outcomes. The overall response rate was 86.8% with a complete response (CR) rate of 17.7%. Among responders, 16.7% of patients sustained THP over 35 months and showed better survivals and higher CR rates. Adverse events were comparable to those reported in previous studies.

Conclusion

In a real-world context, clinical outcomes of Korean HER2-positive MBC patients treated with THP were similar to those of patients in the CLEOPATRA trial. Much longer follow-up results would be warranted.

Real World Evidence of Neoadjuvant Docetaxel/Carboplatin/Trastuzumab/Pertuzumab (TCHP) in Patients with HER2-Positive Early or Locally Advanced Breast Cancer: A Single-Institutional Clinical Experience

Purpose

Docetaxel/carboplatin/trastuzumab/pertuzumab(TCHP) regimen is frequently used to treat early and locally advanced human epidermal growth factor receptor 2(HER2)-positive breast cancer(BC) in neoadjuvant setting. However, large scaled real world evidence did not exist.

Materials and Methods

We retrospectively reviewed medical records of patients with early or locally advanced HER2-positive BC who underwent neoadjuvant TCHP followed by curative surgery at Samsung Medical Center between January 2016 and August 2020.

Results

Of 447 patients, 316 (70.7%) received breast-conserving surgery and 131 (29.3%) received total mastectomy. In terms of NAC response, pathologic complete response (pCR) and residual cancer burden (RCB) score were analyzed. The rate of pCR was 64% a class of RCB 0 was observed in 65% of cases, RCB class I in 12%, RCB class II in 14%, and RCB class III in 2%. The three-year event free survival rate was 90.6%, BC with pCR occurred in 92.8%, and BC with non-pCR in 86.3% (p=0.016). In terms of distant metastasis, the three-year distant recurrence free survival rate was 93.5%; BC with pCR occurred in 95.9% and BC with non-pCR in 89.2% (p=0.013). Mucositis (85.2%), pain (83.2%), and diarrhea (70.5%) were the most common non-hematologic adverse events. In terms of hematologic adverse events, anemia (89.9%) was the most commonly observed adverse events followed by thrombocytopenia (29.8%).

Conclusion

Neoadjuvant TCHP therapy had a pCR rate of 64% and a three-year EFS of 90% in RWE. In terms of toxicity profile, anemia was frequently observed and adequate management including occasional transfusion was required.

Elevated CXCL12 in the plasma membrane of locally advanced rectal cancer after neoadjuvant chemoradiotherapy: a potential prognostic marker

Background: Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC) has been shown to improve sphincter preservation and local pelvic control, but the efficacy of nCRT plateaus due to metastasis. CXC chemokine ligand 12 (CXCL12) has a critical impact on cancer development and metastasis.

Methods: By investigating public databases containing LARC patient data, CXCL12, CXCR4 and FAPα expression was analyzed via the Tumor Immune Estimation Resource (TIMER) and GSEA. Immunohistochemistry was applied to a total of 121 surgically resected specimens consisting of 61 LARCs after nCRT and 60 LARCs with no nCRT and 16 cases with endoscopic resection of high-grade colorectal adenoma.

Results: By investigating public databases containing LARC patient data, CXCL12 expression is correlated with poor prognosis, immune cell infiltration, epithelial- mesenchymal transition, and angiogenesis in LARC. Furthermore, radiation selectively induced CXCL12, CXCR4 and FAPα expression in tumor tissues. Immunohistochemistry results showed that the levels of CXCL12, CXCR4, and FAPα in LARC cells after nCRT were higher than in LARC cells untreated with nCRT (p < 0.001 for each). Elevated levels of CXCL12 in the plasma membrane of LARC cells after nCRT demonstrated an association with the period of freedom from recurrence (FFR) in univariate and multivariate survival analyses (p = 0.005 and p = 0.031, respectively).

Conclusions: The expression of CXCL12 may influence the survival and invasive properties of LARC cells during nCRT and promote cancer recurrence. We suggest that CXCL12 expression in the plasma membrane of radioresistant LARC cells may be a predictive factor of recurrence and a viable therapeutic strategy to control radioresistant LARC recurrence.

Omission of neoadjuvant radiotherapy for clinical T2/N1 and T3N0/1 middle and low rectal cancers with safe circumferential resection margins

Purpose

For moderately advanced rectal cancers with safe circumferential margins, the oncologic benefit of neoadjuvant radiotherapy must be reconsidered because of the possibility of overtreatment, resulting in complications from radiotoxicity. To evaluate the oncologic safety of the omission of neoadjuvant radiotherapy for moderately advanced rectal cancers, we evaluated and compared the prognoses of patients who underwent radical resection with and without neoadjuvant radiotherapy for T2/N1 and T3N0/1 middle and low rectal cancers with safe circumferential resection margins.

Methods

We retrospectively enrolled 66 patients who underwent radical resection for clinical (c) T2N1 and T3N0/1 middle and low rectal cancers between 2008 and 2014. Patients with distant metastasis; cT4, cN2, or positive lateral pelvic lymph nodes; positive circumferential resection margin; signet-ring cell carcinoma; cT1/2N0; or those who had received adjuvant radiotherapy were excluded. The clinical and pathological characteristics and 5-year oncologic outcomes of the no-radiotherapy (n = 34) and radiotherapy (n = 32) groups were compared.

Results

The rates of abdominoperineal resection and ileostomies and the proportion of patients who received adjuvant chemotherapy were significantly higher in the radiotherapy group. There were no significant differences in tumor location, clinical stage, surgery type, pathologic N stage, anastomotic leakage, or long-term oncologic outcomes including 5-year disease-free survival, overall survival, and local recurrence and distant metastasis rates between both groups.

Conclusion

The oncologic benefit of neoadjuvant radiotherapy for cT2/N1 and T3N0/1 middle and low rectal cancers with safe circumferential resection margins is considered unclear, and it can be omitted to prevent radiotoxicity and facilitate prompt essential treatment.

Diagnostic Performance, Stability, and Usability of Self-Collected Combo Swabs and Saliva for Coronavirus Disease 2019 Diagnosis: A Case-Control Study

Background

Self-sampling procedures to detect severe acute respiratory syndrome coronavirus 2 is important for patients who have difficulty visiting the hospital and may decrease the burden for health care workers (HCWs). The objective of this study was to evaluate the diagnostic performance, stability and usability of self-collected nasal and oral combo swabs and saliva specimens.

Materials and Methods

We conducted a case-control study with 50 patients with coronavirus disease 2019 (COVID-19) and 50 healthy volunteers from March, 2021 to June, 2021. We performed real-time reverse-transcription polymerase chain reaction to compare the diagnostic performance of self-collected specimens using positive percent agreements (PPAs).

Results

The PPAs between self-collected and HCW-collected specimens were 77.3 - 81.0% and 80.5 -86.7% for the combo swabs and saliva specimens, respectively. The PPAs increased to 88.9 - 89.2% and 81.2 - 82.1% with a cycle threshold value ≤30.

Conclusion

The diagnostic performance of self sampling was comparable to that of HCW sampling in patients with high viral loads and may thus assist in the early diagnosis of COVID-19.

A Transient Effect of Convalescent Plasma Therapy in a Patient with Severe Covonavirus Disease 2019: A Case Report

A 65-year-old male patient with an end-stage renal disease was diagnosed with coronavirus disease 2019 (COVID-19) by reverse transcription polymerase chain reaction. The patient complained of cough, sputum, and respiratory distress that worsened three days ago. The patient required mechanical ventilation and extracorporeal mentrane oxygenation. On day 9, convalescent plasma collected from a 34-year old man who recovered from COVID-19 45 days ago was administered. The patient showed immediate clinical improvement. However, on day 14, the patient’s clinical course worsened again. On day 19 and day 24, vancomycin-resistant Enterococcus faecium bacteremia and methicillin-resistant Staphylococcus aureus pneumonia were found. After long-term supportive care, he slowly recovered. He was discharged on day 91 without any oxygen requirement. This case report suggests that convalescent plasma therapy might just provide a short-term relief and that persistent effort for critical care is necessary to save patients from severe COVID-19.

Prophylactic use of donut-shaped cushion to reduce sacral pressure injuries during open heart surgery

Background:

Pressure injuries are likely to develop in the operating room due to the high temperature and humidity underneath the patients. This study was designed to reduce sacral pressure injuries using donut-shaped cushions on patients undergoing open heart surgery in a supine position for more than three hours.

Materials and Methods:

Patients undergoing open heart surgery for more than three hours were randomly allocated. Depending on the allocation, either the donut-shaped cushion (donut group) or hydrophilic foam dressing (control group) was applied before draping. Patients were evaluated for the development of pressure injuries, National Pressure Ulcer Advisory Panel (NPUAP) stage, and injury size immediately after surgery, 48 hours, and seven days after surgery.

Results:

Forty-five patients were enrolled in this study. Twenty-two were assigned to the donut group and 23 were assigned to the control group. Three patients developed pressure injuries of NPUAP stage I or higher. All injuries occurred in the control group, but there was no statistically significant difference (P = 0.083).

Conclusions:

Patients who underwent cardiac surgery for more than three hours and used a donut-shaped cushion did not develop pressure injuries, although no statistical difference was noted. Specific preventative measures in the operating room may play a crucial role in preventing pressure injuries, and further research should be pursued.

Are the Current Guidelines Sufficient to Establish Infection Control Strategies for COVID-19 Related Issues in Hospitals?

As hospitals cater to elderly and vulnerable patients, a high mortality rate is expected if a coronavirus disease 2019 (COVID-19) outbreak occurs. Consequently, policies to prevent the spread of COVID-19 in hospital settings are essential. This study was conducted to investigate how effectively national and international guidelines provide recommendations for infection control issues in hospitals. After selecting important issues in infection control, we performed a systematic review and analysis of recommendations and guidelines for preventing COVID-19 transmission within medical institutions at national and international levels. We analyzed guidelines from the World Health Organization, Centers for Disease Control and Prevention, European Centre for Disease Prevention and Control, and Korea Disease Control and Prevention Agency. Recent guidelines do not provide specific solutions to infection control issues. Therefore, efforts need to be made to devise consistent advice and guidelines for COVID-19 control.

430. Strategies for Prevention of COVID-19 Transmission in Hospitals

Background

Infection control measures against the coronavirus disease 2019 (COVID-19) within a hospital often rely on expert experience and intuition due to the lack of clear guidelines. This study surveyed current strategies for the prevention of the spread of COVID-19 in medical institutions.

Methods

Upon systematic review of the guidelines at the national level, 14 key topics were selected. Six hospitals were provided an open survey that assessed their responses to these topics between August 11 and 25, 2020. Using these data, an online questionnaire was developed and sent to the infection control teams of 46 hospitals in South Korea. The survey was conducted between January 31, 2021, and February 20, 2021.

Results

All 46 hospitals responded to the survey, and 24 hospitals (52.2%) had treated 100 or more cases of COVID-19. All hospitals operated screening clinics, and the criteria were respiratory symptoms (100%), fever (97.8%), and epidemiological association (93.5%). It was found that 89.1% (41/46) of hospitals allowed symptomatic patients to visit their general outpatient clinics if fever or respiratory symptoms were not associated with COVID-19. Most hospitals (87.2%; 34/39) conducted polymerase chain reaction (PCR) tests for all hospitalized patients. Moreover, 76.1% (35/46) of hospitals implemented preemptive isolation policies for hospitalized patients, of which 97.1% (34/35) were released from isolation after a single negative PCR test. A little over half of the hospitals (58.7%; 27/46) treated patients that met the national criteria for release from isolation but consistently had positive PCR results. Of these hospitals, 63% (17/27) used N95/KF94 masks, and 40.7% (11/27) used surgical masks without other personal protective equipment for treating them. Most hospitals (76.9%; 20/26) accommodated them in shared rooms when the cycle threshold value of the PCR test was more than a certain value (34.6%; 9/26), or after a certain period that satisfied the national criteria (26.9%; 7/26). Finally, 76.1% (35/46) of hospitals performed emergency procedures or operations on suspected patients.

Table 1. Screening and selective treatment policy to prevent COVID-19 patients from entering the hospital

Note

Values are presented as number (%) Abbreviations: COVID-19, coronavirus disease 2019; PCR, polymerase chain reaction 1 This question requested the respondent to select multiple items. 2 Suspected cases of COVID-19 include fever, respiratory symptoms, and epidemiological associations with COVID-19 patients.

Note

Values are presented as number (%) Abbreviations: COVID-19, coronavirus disease 2019; PCR, polymerase chain reaction; PAPR, powered air-purifying respirator; Ct, cycle threshold 1 This question requested the respondent to select multiple items. 2 It includes infectious diseases, pulmonology, and the infection control and prevention office. 3 One hospital that wrote a non-categorical answer for the question was excluded. The hospital made a decision after discussing it with an infectious diseases specialist.

Conclusion

Various guidelines were being applied by each medical institution, but there was a lack of an explicit set of national guidelines to support them.

Disclosures

All Authors: No reported disclosures

Metabolism perturbation Causedby the overexpression of carbon monoxide dehydrogenase/Acetyl-CoA synthase gene complex accelerated gas to acetate conversion rate ofEubacterium limosumKIST612

Microbial conversion of carbon monoxide (CO) to acetate is a promising upcycling strategy for carbon sequestration. Herein, we demonstrate that CO conversion and acetate production rates of Eubacterium limosum KIST612 strain can be improved by in silico prediction and in vivo assessment. The mimicked CO metabolic model of KIST612 predicted that overexpressing the CO dehydrogenase (CODH) increases CO conversion and acetate production rates. To validate the prediction, we constructed mutant strains overexpressing CODH gene cluster and measured their CO conversion and acetate production rates. A mutant strain (ELM031) co-overexpressing CODH, coenzyme CooC2 and ACS showed a 3.1 × increased specific CO oxidation rate as well as 1.4 × increased specific acetate production rate, compared to the wild type strain. The transcriptional and translational data with redox balance analysis showed that ELM031 has enhanced reducing potential from up-regulation of ferredoxin and related metabolism directly linked to energy conservation.

Clinical and Laboratory Factors Associated with Symptom Development in Asymptomatic COVID-19 Patients at the Time of Diagnosis

In preparation for the surge of coronavirus disease 2019 (COVID-19), it is crucial to allocate medical resources efficiently for distinguishing people who remain asymptomatic until the end of the disease. Between January 27, 2020, and April 21, 2020, 517 COVID-19 cases from 13 healthcare facilities in Gyeonggi province, Korea, were identified out of which the epidemiologic and clinical information of 66 asymptomatic patients at the time of diagnosis were analyzed retrospectively. An exposure-diagnosis interval within 7 days and abnormal aspartate aminotransferase levels were identified as characteristic symptom development in asymptomatic COVID-19 patients. If asymptomatic patients without these characteristics at the time of diagnosis could be differentiated early, more medical resources could be secured for mild or moderate cases in this COVID-19 surge.

Suicide associated with COVID-19 infection: an immunological point of view

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is a pandemic and leading cause of death. Beyond the deaths directly caused by the virus and the suicides related to the psychological response to the dramatic changes as socioeconomic related to the pandemic, there might also be suicides related to the inflammatory responses of the infection. Infection induces inflammation as a cytokine storm, and there is an increasing number of studies that report a relationship between infection and suicide.

MATERIALS AND METHODS

We searched the World Health Organization status report and the PubMed database for keywords (COVID-19, suicide, infection, inflammation, cytokines), and reviewed five cytokine pathways between suicide and inflammation using two meta-analyses and two observational studies starting from November 31, 2020, focusing on the relationship between suicide and inflammation by infection. First, we discussed existing evidence explaining the relationship between suicidal behaviors and inflammation. Second, we summarized the inflammatory features found in COVID-19 patients. Finally, we highlight the potential for these factors to affect the risk of suicide in COVID-19 patients.

RESULTS

Patients infected with COVID-19 have high amounts of IL-1β, IFN-γ, IP10, and MCP1, which may lead to Th1 cell response activation. Also, Th2 cytokines (e.g., IL-4 and IL-10) were increased in COVID-19 infection. In COVID-19 patients, neurological conditions, like headache, dizziness, ataxia, seizures, and others have been observed.

CONCLUSIONS

COVID-19 pandemic can serve as a significant environmental factor contributing directly to increased suicide risk; the role of inflammation by an infection should not be overlooked.

Effects of Saussurea costus on apoptosis imbalance and inflammation in benign prostatic hyperplasia

ETHNOPHARMACOLOGICAL RELEVANCE

Saussurea costus (synonym: Aucklandia lappa Decne) is a medicinal plant distributed in Yunnan, Guangxi, and Sichuan in China. In traditional Korean medicine, the plant parts (especially the root-"radix aucklandiae") is widely used to treat vomiting, diarrhea, and inflammation. However, little has been reported on its effect on benign prostatic hyperplasia (BPH), which is common in middle-aged men.

AIM OF THE STUDY

BPH is caused by apoptosis imbalance and inflammation due to aging of the prostate. Therefore, the aim of this was to prove the efficacy of S. costus by analyzing its effect on the biological mechanisms leading to BPH progression.

MATERIALS AND METHODS

Wistar rats were injected subcutaneously with a single dose of testosterone (125 mg/kg) to induce BPH, and were later administered with S. costus (20, 40 mg/kg). After 12 weeks, histological changes in the prostate and hormone regulation factors were assessed in all animals. Furthermore, apoptotic protein and apoptotic body values were analyzed to confirm the improvement of apoptosis imbalance, and inflammatory cytokines were analyzed to confirm the anti-inflammatory efficacy of S. costus.

RESULTS

In the serum and tissue of S. costus-treated BPH rats, a significant reduction in prostate weight, prostate index, and hormone regulation factors was observed. S. costus also increased the levels of apoptosis marker proteins and reduced the levels of inflammatory cytokines. It also decreased the expression of B-cell lymphoma 2 (BCL-2) and increased the expression of BCL-2 associated X protein (BAX) in the prostate. Histological changes such as epithelial thickness significantly increased in BPH induced group but significantly decreased in the S. costus-treated groups (p < 0.001).

CONCLUSIONS

S. costus may prevent and treat BPH occurrence by modulating inflammation and apoptosis imbalance.

Which Clinicopathologic Parameters Suggest Primary Resistance to Palbociclib in Combination With Letrozole as the First-Line Treatment for Hormone Receptor-Positive, HER2-Negative Advanced Breast Cancer?

In this study, we evaluated clinical parameters to predict the primary resistance of palbociclib in combination with endocrine therapy as the first-line treatment in patients with hormone receptor (HR)+, human epidermal growth factor receptor 2 (HER2)- metastatic breast cancer (MBC). We performed a data analysis of patients diagnosed with HR+, HER2-MBC who received palbociclib plus letrozole as the first-line treatment in the metastatic setting from the clinical data warehouse in Samsung Medical Center. In this study, 305 patients were included in the final data analysis. The median follow-up duration was 31 months, and we observed 123 cases of disease progression. The median progression-free survival (PFS) was 28.7 months, and 38 patients (12.5%) had less than a 6-month PFS. The multivariate analysis suggested that primary resistance to adjuvant endocrine therapy (ET) (hazard ratio: 1.91), presence of liver metastasis (hazard ratio: 2.17), initial elevation of serum CA-15-3 (hazard ratio: 1.99), weak positivity of estrogen receptor (ER) (hazard ratio: 2.28), Ki-67 3+ or 4+ (hazard ratios: 2.58 and 10.28), and presence of mutation (hazard ratio: 9.59) were associated with a short PFS duration. A further prediction model was developed with data from 256 patients and 33 cases of disease progression in 6 months. This model included five factors-primary resistance to adjuvant ET (odds ratio, OR: 1.14), liver metastasis (OR: 1.56), initial CA-15-3 elevation (OR: 1.51), weak ER expression (OR: 2.22), and BRCA2 mutation (OR: 2.85)-and the area under the receiver operating characteristic curve was 0.842 (95% CI: 0.775, 0.909; p < 0.001). Finally, we divided them into four risk groups according to the prediction model with the five risk factors. These four groups had different PFS (p < 0.001) and primary resistance of palbociclib with letrozole [OR of group 2 vs. group 1 (ref): 2.18 (p = 0.002), OR of group 3: 3.91 (p < 0.001), and OR of group 4: 4.25 (p < 0.001)]. We developed a prediction model of primary resistance to palbociclib with letrozole as the first-line treatment for HR+, HER2-MBC. Our prediction model might be helpful for considering the first-line treatment strategies. Further well-designed clinical trials would be warranted to validate our prediction model.

Mass Lesions That Almost Fill the Ascending Aorta: When to Operate?

Although anticoagulation can be an option for the resolution of thrombus, surgical removal is a definite treatment for removing mass lesions, especially in patients with unknown pathology. The present case report demonstrates the surgical removal of a sarcoma of the ascending aorta after the failure of anticoagulation. (Level of Difficulty: Advanced.)