An Exploration of Care Mapping Among Families of Children with Medical Complexity (CMC)

BACKGROUND: A care map is a visual diagram that illustrates all of the resources needed to support a child with medical complexity, providing a contextualized view of the child in a broader health network. It is believed that health care providers (HCPs) can utilize care maps to enable child and family centered care by helping families prioritize and coordinate their health needs. While the popularity of care maps has been growing, there is a paucity of research on their clinical usefulness.

OBJECTIVES: The objective of this study is to explore how care maps are constructed by parents, what they mean for parents and HCPs, and how they can be applied in a clinical setting.

DESIGN/METHODS: This is a qualitative study informed by a grounded theory approach. Theoretical sampling of parents and HCPs of CMC was utilized. Fifteen care map training sessions and forty-five semi-structured interviews with parents and HCPs of CMC were conducted. The data was coded and analyzed iteratively for predominant themes and emerging theory.

RESULTS: Both HCPs and parents strongly identified the care map [Figure 1] as a valuable tool in the care of CMC. Data analysis revealed key themes that demonstrated how and why care maps are useful. Care maps allow HCPs to recognize family experiences, identify parental goals of care and promote improved care coordination and communication. Parents described creating care maps as an empowering and therapeutic process that helped them to organize and communicate their complex interplay of supports. Both parents and HCPs acknowledged challenges associated with care mapping including the ability of parents to create a care map as well as the HCPs ability to independently interpret the care map’s meaning.

CONCLUSION: Care maps are a useful communication and coordination tool to demonstrate a contextualized view of a family’s narrative of their experience caring for a CMC. Findings may inform a model of how to utilize care maps in clinical practice.

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Exfoliated Graphene Oxide/MoO2 Composites as Anode Materials in Lithium-Ion Batteries: An Insight into Intercalation of Li and Conversion Mechanism of MoO2

Exfoliated graphene oxide (EG)/MoO2 composites are synthesized by a simple solid-state graphenothermal reduction method. Graphene oxide (GO) is used as a reducing agent to reduce MoO3 and as a source for EG. The formation of different submicron sized morphologies such as spheres, rods, flowers, etc., of monoclinic MoO2 on EG surfaces is confirmed by complementary characterization techniques. As-synthesized EG/MoO2 composite with a higher weight percentage of EG performed excellently as an anode material in lithium-ion batteries. The galvanostatic cycling studies aided with postcycling cyclic voltammetry and galvanostatic intermittent titrations followed by ex situ structural studies clearly indicate that Li intercalation into MoO2 is transformed into conversion upon aging at low current densities while intercalation mechanism is preferably taking place at higher current rates. The intercalation mechanism is found to be promising for steady-state capacity throughout the cycling because of excess graphene and higher current density even in the operating voltage window of 0.005-3.0 V in which MoO2 undergoes conversion below 0.8 V.

Abstract P4-14-21: A phase I trial of ganetespib (heat shock protein 90 inhibitor) in combination with paclitaxel and trastuzumab in patients with human epidermal growth factor receptor-2 positive (HER2+) metastatic breast cancer (MBC)

Introduction: Targeted therapies in HER2+ MBC significantly improve outcomes but efficacy is limited by therapeutic resistance. HSP90 is a molecular chaperone involved in the stability and function of multiple signaling onco-proteins. HER2 is an acutely sensitive HSP90 client and HSP90 inhibition can overcome trastuzumab resistance. Our group reported objective responses with 17-AAG plus trastuzumab in HER2+ MBC. Ganetespib, a synthetic, second generation HSP90 inhibitor has increased potency and tolerability compared with earlier agents. We reported anti-tumor activity in metastatic HER2+ and triple negative breast cancer with single agent ganetespib. Preclinically, HSP90 inhibition has synergistic anti-tumor activity with taxanes and trastuzumab. This study will define the MTD and RP2D of ganetespib plus paclitaxel and trastuzumab in HER2+ MBC.

Methods: In this 3+3 phase I dose escalation study, patients with trastuzumab-resistant HER2+ MBC receive weekly trastuzumab and paclitaxel (80mg/m2) with ganetespib on day 1, 8, 15 of a 28 day cycle. HR+ positive patients are required to have at least one prior line of endocrine therapy. DLT of ganetespib monotherapy is diarrhea and therefore patients receive prophylactic anti-motility agents. Based on prior experience with ganetespib plus docetaxel in NSCLC, only 3 dose levels of ganetespib were explored: 100mg/m2, 150mg/m2 and a 3rd cohort of 125mg/m2, if needed. Secondary endpoints include evaluation of effects of ganetespib on the pharmacokinetics (PK) of paclitaxel and preliminary efficacy assessment.

Results: The dosing cohorts (100 mg/m2 (n=3) and 150 mg/m2 (n=6)) have been completed without any DLTs. Median age was 46 years (range 29-65), median prior lines of chemotherapy and anti-HER2 therapy were 3 (range 2-6) and 3 (range 2-4) respectively, including prior pertuzumab in 9/9 and T-DM1 in 8/9 patients. There were no grade 3/4 adverse events (AEs) related to ganetespib. Most common AEs related to ganetespib were diarrhea, fatigue, anemia and rash. Paclitaxel PK data available from 6/9 patients are not appreciably different from those reported in literature. Overall response rate was 25% (2/8 had PR in 150 mg/m2 cohort; 1 patient was not evaluable), SD in 63% (5/8), and clinical benefit rate (CR+PR+SD>24 weeks) was 50% (4/8). 3 patients remain on study.

Conclusion: The RP2D of ganetespib is 150mg/m2 in combination with paclitaxel and trastuzumab. The combination was safe and well tolerated. Updated PFS and PK data will be presented. Despite prior taxanes, pertuzumab and T-DM1, clinical activity of this triplet regimen in this heavily pre-treated cohort is very promising and together with our prior experience with 17-AAG plus trastuzumab and single agent ganetespib warrants further study in HER2+ MBC. A phase 2 trial is being planned in trastuzumab-refractory HER2+ MBC who have progressed on prior pertuzumab and T-DM1. Additionally, the protocol is amended to assess the safety of ganetespib in combination with paclitaxel, trastuzumab and pertuzumab in the first-line setting.

Citation Format: Jhaveri K, Teplinsky E, Chandarlapaty S, Solit D, Cadoo K, Speyer J, D'Andrea G, Adams S, Patil S, Haque S, Friedman K, Neville D, Esteva F, Hudis C, Modi S. A phase I trial of ganetespib (heat shock protein 90 inhibitor) in combination with paclitaxel and trastuzumab in patients with human epidermal growth factor receptor-2 positive (HER2+) metastatic breast cancer (MBC). [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 P4-14-21.

Abstract S1-03: Pooled individual patient data analysis of stromal tumor infiltrating lymphocytes in primary triple negative breast cancer treated with anthracycline-based chemotherapy

Background:

Retrospective analyses from individual clinical trials have suggested that host anti-tumor immunity as measured by stromal tumor infiltrating lymphocytes (TILs) is important for the outcomes of the primary triple negative breast cancer (TNBC) subgroup, but the clinical utility of TILs in day-to-day management of primary TNBC is still limited. Our objective was to conduct a pooled analysis of the clinical trials that have investigated TILs in TNBC patients treated by anthracyclines-based (A) chemotherapy regimens in order to gain a robust understanding of the prognostic value of TILs in this setting.

Material and methods:

Methods were predefined in a protocol. Eligible studies were randomized clinical trials that have evaluated the prognostic associations of TILs (evaluated in the same manner) in patients diagnosed with early stage TNBC treated with A or A plus taxanes (A+T). Cox regression models stratified by trial for invasive disease-free survival (IDFS, primary endpoint) and overall survival (OS), fitting stromal TILs as a continuous variable.

Results:

We collected individual data from 991 TNBC patients included in 6 randomized clinical trials (ECOG2197, ECOG1199, BIG2-98, FinHER, 2 from Gustave Roussy): 62% of patients were treated by A+T and 38% by A alone; 32% of patients had no nodal involvement, 43% of patients had 1-3 nodes and 25% patients more than 3 nodes involved. The average age was 49 years (range 22.6-85 yrs) and the average tumor size 3.0 cm (sd 1.7).

Across the entire data set, the average value of stromal TILs was 20% (sd 17%); 90% of patients had at least 1% stromal TILs. After adjusting for trial, stromal TILs were significantly lower with increasing tumor size (linear model, p<0.0001) but not significantly associated with nodal status categories (p=0.52 and p=0.37) nor age (p=0.25). With a median follow-up of 6.6 years for IDFS and 7.3 years for OS, a total of 363 IDFS events and 273 deaths were observed. Each 10% increase in stromal TILs was associated with a 14% relative reduction in IDFS events (HR=0.86, 95% 0.80 to 0.93, p<0.0001) and a 17% relative reduction in deaths (HR=0.83, 95% CI 0.76 to 0.91, p=0.0001). There was no significant evidence for heterogeneity between trials for IDFS (chi2=4.55, p=0.34) nor for OS (chi2=4.45, p=0.34).

In a multivariable analysis adjusted for age, nodal status, tumor size and chemotherapy regimen, stromal TILs added significant independent prognostic information for both IDFS and OS (likelihood chi2=17.9 for IDFS, p<0.0001 and chi2=16.7 for OS, p<0.0001). The adjusted hazard ratio for each 10% increase in stromal TILs was HR=0.86 (0.76-0.92) for IDFS events and HR=0.84 (0.76-0.92) for death.

Conclusion:

This large pooled individual patient data analysis confirms the strong prognostic role of stromal TILS in primary TNBC treated with A or A+T. TILs should now be strongly considered for incorporation as a stratification factor in future clinical trials enrolling TNBC patients. Given the important prognostic role of pre-existing immunity, patients with TNBC are rational candidates for immunotherapy clinical trials.

Funding:Ligue Nationale Contre le Cancer.

Citation Format: Loi S, Drubay D, Adams S, Francis PA, Joensuu H, Dieci MV, Badve S, Demaria S, Gray R, Piccart MJ, Kellokumpa-Lehtinen P-L, Andre F, Dufaure-Gare I, Denkert C, Salgado R, Michiels S. Pooled individual patient data analysis of stromal tumor infiltrating lymphocytes in primary triple negative breast cancer treated with anthracycline-based chemotherapy. [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 S1-03.

Abstract P2-11-11: Phase II trial of exemestane with immunomodulatory oral cyclophosphamide in metastatic hormone receptor (HR)-positive breast cancer: Prolonged progression-free survival (PFS) in patients with distinct T regulatory cell (Treg) profile

Background: Resistance to endocrine therapies in HR-positive breast cancer is a significant challenge. The steroidal aromatase inhibitor (AI) exemestane (EXE) has demonstrated short-term efficacy in metastatic HR-positive HER2-negative breast cancer (mHR+BC) that has progressed during treatment with a non-steroidal AI. Combination strategies have not shown a survival benefit. Immunotherapy represents a promising approach as it may increase durability of responses. Low dose cyclophosphamide (CTX) has demonstrated efficacy in combination with neoadjuvant letrozole in HR+BC, conceivably by enhancing anti-tumor immune responses. Here we investigated whether EXE combined with immunomodulatory CTX could provide durable responses in heavily pretreated patients and assessed immunological profiles (NCT01963481).

Methods: Phase II trial of EXE (25mg PO daily) with CTX (50 mg PO daily) enrolled postmenopausal women (n=23) with mHR+BC who had progressed on prior endocrine therapy (including nonsteroidal AI, tamoxifen, and/or fulvestrant); prior chemotherapy was allowed. The primary endpoint was PFS (per RECIST 1.1) at 3 months; secondary endpoints were response rate, tolerability, and immune correlates. Detailed functional immune profiling of peripheral T cell subsets were performed by flow cytometry at baseline, 1, 3, 6, 9 & 12 months, with healthy donors available as controls.

Results: All 23 patients have been enrolled, and 21 are evaluable for response. Median age was 54 (range 31-77), median prior lines of endocrine therapy was 2 (1-3) and chemotherapy was 1 (0-5). The majority (15/23) had visceral organ involvement. Combination treatment was well tolerated with one grade 3 urinary tract infection but no grade 4 or 5 toxicity. An objective response was observed in 19% of patients (4/21, 1 CR and 3 PR) and an additional 33% (7/21) had SD, resulting in a 3-month-PFS of 48.5% (95% CI, 30.5-77.1). Responses were durable in all patients, lasting =/> 9 months and included patients with liver metastases.

Comparison of peripheral immune cell subsets of patients (n=16) at baseline to age/sex-matched healthy controls demonstrated an increased proportion of CD4+ memory T cells with central memory phenotype (CD45RO+CD27+, p<0.0001). When patients were stratified based on PFS at 3 months, the proportion of naïve Tregs (CD4+CD45RO-FOXP3+Helios+) at baseline was significantly lower (p=0.003) in the non-progressor group compared to patients with progression. Remarkably, when these patient groups were compared for changes in T cell subsets during treatment, the proportion of both naïve and memory Treg subsets increased from baseline to 3 months (p<0.01), but only in the non-progressor patient group. While preliminary, these findings are possibly indicative of novel predictive biomarkers.

Conclusion: EXE and CTX had a favorable safety profile with evidence of clinical activity in patients with heavily pretreated mHR+BC, including durable responses in liver and bone. Correlative studies are ongoing to identify potential biomarkers of response or resistance to therapy.

Citation Format: Kwa M, Novik Y, Oratz R, Jhaveri K, Wu J, Gu P, Meyers M, Muggia F, Bonakdar M, Abidoglu C, Kozhaya L, Li X, Joseph B, Iwano A, Friedman K, Goldberg JD, Unutmaz D, Adams S. Phase II trial of exemestane with immunomodulatory oral cyclophosphamide in metastatic hormone receptor (HR)-positive breast cancer: Prolonged progression-free survival (PFS) in patients with distinct T regulatory cell (Treg) profile. [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 P2-11-11.

Tropical Pyomyositis in a Temperate Climate

In conclusion, our case highlights the unusual presentation of tropical pyomyositis in a temperate environment. It is important to consider this diagnosis in immunocompromised hosts, even in those with vague complaints such as muscle pain or erythema. The patient's immunocompromised state as well as the rarity of tropical pyomyositis outside of a tropical country led to a late diagnosis. Tropical pyomyositis is a potentially life threatening disease, but if recognized and treated early, the prognosis is good.

Abstract POSTER-BIOL-1320: Rho-family GTPases as therapeutic targets in ovarian cancer

Purpose of the study: Although Rac1 and Cdc42 are considered attractive therapeutic targets, no selective inhibitors of these GTPases are in clinical trials. The Ras-homologous (Rho) family GTPases Rac1 and Cdc42 contribute to metastatic dissemination through regulation of actin reorganization, cell motility, cell-cell and cell-extracellular matrix adhesion. Using high throughput screening and cheminformatics, we identified the R-enantiomer of ketorolac as a novel inhibitor of Rac1 and Cdc42. R-enantiomers of nonsteroidal anti-inflammatory drugs are poor inhibitors of cyclooxygenase (COX) activity, yet little is known about the pharmacologic activities or targets of the R-enantiomers. The purpose of this study was to investigate the effects of R-ketorolac on ovarian cancer.

Experimental procedures: GTPase target expression and activity was determined by immunohistochemistry, RT-PCR and enzymatic assays. The effects of racemic, R- and S-ketorolac on proliferation, adhesion and migration were investigated using human ovarian tumor cells (OvCA 429 and SKOV3ip). In vivo effect of ketorolac treatments was determined in a xenograft model using SKOV3ip cells. Pharmacokinetic and pharmacodynamic assessments of racemic R/S-ketorolac (Toradol®) in patients were conducted in women with suspected advanced stage ovarian, fallopian tube or primary peritoneal cancer with planned optimal cytoreductive surgery. Ascites samples were obtained for measurement of cell adhesion and drug inhibition of GTPase activity. After placement of an IP port the recommended dose of IV racemic ketorolac was administered and blood and peritoneal fluid were obtained at T=0, 1h, 6h and 24h. R- and S-ketorolac concentrations in serum and peritoneal fluid were measured by HPLC. GTPase inhibitory activity of ketorolac was assessed in peritoneal tumor cells.

Summary of the data: Elevation of Cdc42 protein and expression of the constitutively active Rac1b splice variant of Rac1 were detected in ovarian cancer specimens providing the first evidence for dysregulation of these GTPase targets in ovarian cancer. R-ketorolac, and not S-ketorolac, inhibits Rac1 and Cdc42 activity demonstrating an unexpected pharmacologic activity for the R-enantiomer. R-ketorolac, but not S-ketorolac, inhibits cell adhesion and migration, and reduced peritoneal tumor implantation in a mouse xenograft model. In the clinical studies using R/S-ketorolac for post-operative pain management, we found that ketorolac distributed to peritoneal fluids within 6 hours and fluids were highly enriched in the R-enantiomer compared to the S-enantiomer. Rac1 and Cdc42 activity was inhibited in ovarian tumor cells retrieved from the peritoneal cavity post-ketorolac administration. Cell adhesion was decreased by R-ketorolac in patient-derived ovarian tumor cells.

Conclusions: The findings show R-ketorolac is a novel inhibitor of Rac1 and/or Cdc42, and active in ovarian cancer model systems. The favorable distribution of R-ketorolac in the peritoneal cavity coupled with GTPase inhibition in cells retrieved from the intraperitoneal compartment support the potential benefit of R-ketorolac for ovarian cancer patients.

Citation Format: Hudson LG, Kenney SR, Guo Y, Adams S, Rutledge T, Muller CY, Wandinger-Ness A. Rho-family GTPases as therapeutic targets in ovarian cancer [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr POSTER-BIOL-1320.

R-Ketorolac Targets Cdc42 and Rac1 and Alters Ovarian Cancer Cell Behaviors Critical for Invasion and Metastasis

Cdc42 (cell division control protein 42) and Rac1 (Ras-related C3 botulinum toxin substrate 1) are attractive therapeutic targets in ovarian cancer based on established importance in tumor cell migration, adhesion, and invasion. Despite a predicted benefit, targeting GTPases has not yet been translated to clinical practice. We previously established that Cdc42 and constitutively active Rac1b are overexpressed in primary ovarian tumor tissues. Through high-throughput screening and computational shape homology approaches, we identified R-ketorolac as a Cdc42 and Rac1 inhibitor, distinct from the anti-inflammatory, cyclooxygenase inhibitory activity of S-ketorolac. In the present study, we establish R-ketorolac as an allosteric inhibitor of Cdc42 and Rac1. Cell-based assays validate R-ketorolac activity against Cdc42 and Rac1. Studies on immortalized human ovarian adenocarcinoma cells (SKOV3ip) and primary patient-derived ovarian cancer cells show that R-ketorolac is a robust inhibitor of growth factor or serum-dependent Cdc42 and Rac1 activation with a potency and cellular efficacy similar to small-molecule inhibitors of Cdc42 (CID2950007/ML141) and Rac1 (NSC23766). Furthermore, GTPase inhibition by R-ketorolac reduces downstream p21-activated kinases (PAK1/PAK2) effector activation by >80%. Multiple assays of cell behavior using SKOV3ip and primary patient-derived ovarian cancer cells show that R-ketorolac significantly inhibits cell adhesion, migration, and invasion. In summary, we provide evidence for R-ketorolac as a direct inhibitor of Cdc42 and Rac1 that is capable of modulating downstream GTPase-dependent, physiologic responses, which are critical to tumor metastasis. Our findings demonstrate the selective inhibition of Cdc42 and Rac1 GTPases by an FDA-approved drug, racemic ketorolac, that can be used in humans.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Facile one pot synthesis and Li-cycling properties of MnO2

MnO₂ compounds prepared by a molten salt method (MSM) using three different Mn-salts and studied for its electrochemical properties.

Sodium-ion diffusion mechanisms in the low cost high voltage cathode material Na2+δFe2−δ/2(SO4)3

Bond-valence site energy modelling, molecular dynamics and DFT simulations jointly clarify Na⁺-ion migration in Na_2+δFe_2−δ/2(SO₄)₃, a promising high voltage cathode material for sodium-ion batteries, and the role of Fe²⁺ vacancies therein.

Comparison of the effects of active, passive and mixed warm ups on swimming performance

AIM

The aim of this paper was to compare the effects of an active (AWU), passive (PWU) and mixed warm up (MWU) on swimming performance.

METHODS

Eight male competitive swimmers completed each type of WU and, following a 20-minute rest, performed a maximum 100m test on their specialised stroke. The order of WUs was randomized and there was a 7-day period between subsequent testing sessions. The time taken to complete the 100m trial was the performance measure. The rating of perceived exertion (RPE) was measured immediately post WU, while heart rate (HR) was measured pre and post WU and pre and post the maximum swim. During the 20-minute rest, the swimmers' psychological state was assessed with the CSAI-2 questionnaire.

RESULTS

Post WU HR and RPE had the lowest values following the AWU and the highest values following the PWU (P<0.01). No other significant differences were found in any variables. Pre performance HR increased significantly relative to pre WU HR for all conditions (P≤0.01). Swimmers had relatively low levels of anxiety and modest to high levels of self confidence for all conditions.

CONCLUSIONS

No WU appeared to be superior to the others with respect to swimming performance. The MWU produced nearly identical values to the AWU for most variables, and was therefore found to be an appropriate alternative WU type that swimmers may use before competition. The PWU also seemed to be appropriate, but the somewhat worse performance and lower cognitive anxiety and self confidence scores recorded, albeit non-significant, suggested that more swimmers and distances are tested before any firm conclusions regarding its effectiveness can be drawn.

Efficacy, safety and usability of secukinumab administration by autoinjector/pen in psoriasis: a randomized, controlled trial (JUNCTURE)

BACKGROUND

Secukinumab is a fully human anti-interleukin-17A monoclonal antibody.

OBJECTIVE

Determine the efficacy, safety and usability of secukinumab administered via autoinjector/pen.

METHODS

This phase III trial randomized subjects with moderate to severe plaque psoriasis to secukinumab 300 mg, 150 mg or placebo self-injection once weekly to Week 4, then every 4 weeks. Co-primary end points at Week 12 were ≥75% improvement in Psoriasis Area and Severity Index (PASI 75) and clear/almost clear skin by investigator's global assessment 2011 modified version (IGA mod 2011 0/1). Secondary end points included autoinjector usability, assessed by successful, hazard-free self-injection and subject-reported acceptability on Self-Injection Assessment Questionnaire.

RESULTS

Week 12 PASI 75 and IGA mod 2011 0/1 responses were superior with secukinumab 300 mg (86.7% and 73.3%, respectively) and 150 mg (71.7% and 53.3%, respectively) vs. placebo (3.3% and 0%, respectively) (P < 0.0001 for all). All subjects successfully self-administered treatment at Week 1, without critical use-related hazards. Subject acceptability of autoinjector was high throughout 12 weeks. Adverse events were higher with secukinumab (300 mg, 70.0%; 150 mg, 63.9%) vs. placebo (54.1%), with differences largely driven by mild/moderate nasopharyngitis.

CONCLUSION

Secukinumab delivered by autoinjector/pen is efficacious, well-tolerated and associated with high usability in moderate to severe plaque psoriasis.

The evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an International TILs Working Group 2014

BACKGROUND

The morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is gaining momentum as evidence strengthens for the clinical relevance of this immunological biomarker. Accumulating evidence suggests that the extent of lymphocytic infiltration in tumor tissue can be assessed as a major parameter by evaluation of hematoxylin and eosin (H&E)-stained tumor sections. TILs have been shown to provide prognostic and potentially predictive value, particularly in triple-negative and human epidermal growth factor receptor 2-overexpressing BC.

DESIGN

A standardized methodology for evaluating TILs is now needed as a prerequisite for integrating this parameter in standard histopathological practice, in a research setting as well as in clinical trials. This article reviews current data on the clinical validity and utility of TILs in BC in an effort to foster better knowledge and insight in this rapidly evolving field, and to develop a standardized methodology for visual assessment on H&E sections, acknowledging the future potential of molecular/multiplexed approaches.

CONCLUSIONS

The methodology provided is sufficiently detailed to offer a uniformly applied, pragmatic starting point and improve consistency and reproducibility in the measurement of TILs for future studies.

Big Data in Healthcare - Defining the Digital Persona through User Contexts from the Micro to the Macro. Contribution of the IMIA Organizational and Social Issues WG

OBJECTIVES

While big data offers enormous potential for improving healthcare delivery, many of the existing claims concerning big data in healthcare are based on anecdotal reports and theoretical vision papers, rather than scientific evidence based on empirical research. Historically, the implementation of health information technology has resulted in unintended consequences at the individual, organizational and social levels, but these unintended consequences of collecting data have remained unaddressed in the literature on big data. The objective of this paper is to provide insights into big data from the perspective of people, social and organizational considerations.

METHOD

We draw upon the concept of persona to define the digital persona as the intersection of data, tasks and context for different user groups. We then describe how the digital persona can serve as a framework to understanding sociotechnical considerations of big data implementation. We then discuss the digital persona in the context of micro, meso and macro user groups across the 3 Vs of big data.

RESULTS

We provide insights into the potential benefits and challenges of applying big data approaches to healthcare as well as how to position these approaches to achieve health system objectives such as patient safety or patient-engaged care delivery. We also provide a framework for defining the digital persona at a micro, meso and macro level to help understand the user contexts of big data solutions.

CONCLUSION

While big data provides great potential for improving healthcare delivery, it is essential that we consider the individual, social and organizational contexts of data use when implementing big data solutions.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

OBJECTIVE

Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge.

METHODS

Within the Pediatric ED (PED) at a tertiary children's hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart.

RESULTS

Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%.

CONCLUSIONS

This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.

The immunomodulatory effects of pegylated liposomal doxorubicin are amplified in BRCA1--deficient ovarian tumors and can be exploited to improve treatment response in a mouse model

OBJECTIVE

Women with BRCA-associated ovarian cancer demonstrate excellent responses to Pegylated Liposomal Doxorubicin (PLD). PLD has also been shown to enhance T cell recognition of tumor cells. Here we characterize immunophenotypic changes associated with BRCA1 dysfunction in ovarian cancer cells, and evaluate the T cell contribution to the therapeutic efficacy of PLD in a BRCA1- ovarian cancer model to determine whether enhanced anti-tumor immunity contributes to the improved response to PLD in BRCA1- ovarian cancers.

METHODS

The immunophenotype of BRCA1- and wild-type (WT) ovarian cancer cells and their response to PLD were compared in vitro using flow cytometry. T cell recruitment to BRCA1- tumors was evaluated with flow cytometry and immunohistochemistry. The contribution of T cell populations to the therapeutic effect of PLD in a BRCA1- model was evaluated using immunodepleting antibodies with PLD in vivo.

RESULTS

The cytotoxic response to PLD was similar in BRCA1- and WT cells in vitro. BRCA1- inactivation resulted in higher expression of Fas and MHC-I at baseline and after PLD exposure. PLD prolonged the survival of BRCA1- tumor bearing mice and increased intratumoral T cell recruitment. CD4+ depletion combined with PLD significantly prolonged overall survival (p=0.0204) in BRCA1- tumor-bearing mice.

CONCLUSION

Differences in the immunophenotype of BRCA1- and WT cells are amplified by PLD exposure. The enhanced immunomodulatory effects of PLD in BRCA1- tumors may be exploited therapeutically by eliminating suppressive CD4+ T cells. Our results support further study of combination therapy using PLD and immune agents, particularly in women with BRCA gene mutations.

Abstract OT2-1-02: Novel combination of toll-like receptor (TLR)-7 agonist imiquimod and local radiotherapy in the treatment of breast cancer chest wall recurrences or skin metastases

Background/Rationale: To assess the immune and systemic anti-tumor effects of the novel combination of local radiotherapy combined with imiquimod applied topically to breast cancer metastatic to skin. Breast cancer is the most common tumor, excluding melanoma, to metastasize to the skin in women. Chest wall recurrence is debilitating for patients, substantially affecting quality of life. Current treatment modalities for unresectable lesions are rarely curative and patients ultimately die of visceral metastases, indicating the need for more effective therapies. Imiquimod (IMQ), a synthetic TLR-7 agonist has immunomodulatory activity with profound effects on the tumor environment and can lead to tumor regression of cutaneous breast cancer metastases (Adams et al, Clin Ca Res, Dec 15, 2012). Accumulating evidence indicates that the potential of local radiotherapy to convert the tumor into an in-situ vaccine can be enhanced by combination with immunotherapy to achieve a therapeutic synergy. We have previously shown in a mouse model of cutaneous breast cancer that topical IMQ synergizes with local RT to induce complete tumor regression (REF). Importantly, this approach used a local treatment to generate anti-tumor immune responses with ability to control the tumor systemically (Dewan et al, Clin Ca Res Dec 15, 2012). This trial was designed to test the feasibility of translating this therapeutic synergy in the clinic (clinicaltrials.gov NCT01421017).

Methods: Eligibility includes patients with biopsy-confirmed breast cancer, measurable disease and skin metastases, ECOG PS 0-2 and adequate organ/marrow function. Radiation therapy is delivered to one area of skin metastases in five fractions of 6 Gy (days 1,3,5,8,10). IMQ 5% cream is applied topically to skin metastases overnight for 5 days/week for 8 weeks, beginning the evening of the first radiotherapy. Continuous imiquimod to all skin metastases even after completion of RT is based on our preclinical evidence of an improved effector phase of the immune response. Additional treatment cycles with IMQ/RT are permitted. Following a brief phase I portion to allow dose optimization in the event of unanticipated adverse events (3-3 design), the phase II study evaluates efficacy with a planned additional 25 patients. Primary endpoint is the response rate in untreated metastases, assessed by immune-related response criteria. Furthermore, the local tumor responses and safety of the combination will be determined; tumor FNA biopsies will be obtained to investigate signatures of immune-mediated rejection as recently described with IMQ mediated rejection of basal cell carcinomas; and peripheral lymphocytes will be examined for the induction/boosting of selected tumor antigen-specific T and B cell responses.

The phase I portion has been successfully completed with 6 patients without DLT. Enrollment into the phase II portion has begun. At present, a total of 11 patients have been enrolled.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-1-02.

Prior hormonal treatment, but not sexual experience, reduces the negative effects of restraint on female sexual behavior

These experiments were designed to determine if prior sexual experience reduced the negative effect of mild stress on female sexual behavior. In the first experiment, ovariectomized rats were hormonally primed with estradiol benzoate and progesterone for 3 consecutive weeks during which they received six mating experiences in a male's home cage or received no sexual experience. The next week, females were primed with 10 μg estradiol benzoate two days before a 5 min restraint. Both groups were resistant to the negative effects of the stressor. In the second experiment, females received 0, 1, 2, or 3 weeks of 10 μg estradiol benzoate and were restrained on the fourth week after priming with 10 μg estradiol benzoate. Rats without prior hormonal priming showed a decline in lordosis behavior after restraint but prior priming with estradiol benzoate reduced this effect. In the third experiment, rats received 3 weeks of hormonal priming with estradiol benzoate and progesterone with or without sexual experience. An additional group received no sexual experience or hormonal priming. Females were then given a 3-week hormone vacation before testing in the restraint paradigm. All groups showed a decline in lordosis behavior after restraint. The fourth experiment was identical to the third except that sexual experience in the male's cage and in a pacing apparatus were compared. There was no effect of either type of sexual experience on the response to restraint. Possible mechanisms responsible for effects of prior hormonal priming are presented and the absence of an effect of sexual experience is discussed in comparison to findings in male rats.

Abstract B81: Selected NSAIDs target GTPases for ovarian cancer therapy

Rac1 and Cdc42 GTPases are key regulators of actin reorganization, cell mobility, cell-cell and cell-extracellular matrix (ECM) adhesion, whose activities are found closely correlated with tumor cell properties (increased proliferation, migration and adhesion), which are important for tumor expansion and malignant progression. We found that both the constitutively active Rac1b and Cdc42 GTPases are overexpressed in primary ovarian tumors and cancer cell lines. Using high throughput screening and computational methods, selected non-steroidal anti-inflammatory drugs (NSAIDs) were identified as regulators of Rac1 and Cdc42 in vitro, which we confirmed in cellular assays and xenograft animal model studies. Among the NSAIDs, ketorolac, inhibited cell adhesion, migration and invasion. When administrated intraperitoneally (IP) in a human xenograft model of ovarian cancer a 3-4 fold reduction in tumor cell number and decreased total tumor burden resulted. The S-enantiomer of ketorolac is a well-established inhibitor of cyclooxygenase (COX) enzymes. We determined that R-enantiomer had little activity against COX and using G-LISA assays to measure GTPase activation established that R-, but not S-ketorolac was an effective GTPase inhibitor. These data prompted us to conduct a clinical pilot study in ovarian cancer patients assessing the bioavailability and impact of clinically approved Toradol (racemic [R, S] ketorolac administrated clinically for pain after surgery) on tumor cell behaviors. Patient serum and ascites samples analyzed by HPLC established that ketorolac was detectable in the ascites fluid within 1 hour after intravenous (IV) administration with predominantly the R-form persisting after 6 hours. Serum concentrations were found to predict ascites concentrations. Purified tumor cells from fresh patient ascites (identified by tumor markers MUC16, EpCAM) when treated in vitro with ketorolac exhibited reduced adhesion to ECM; furthermore, GTPase activity assays demonstrated that R-, but not S-ketorolac significantly inhibited Cdc42 activity. Post-Toradol treatment patient ascites samples also exhibited reduced Cdc42 activity at all timepoints. In sum, we show that the R-enantiomers of selected NSAIDs are novel chemical entities that selectively target Rho-family GTPases and facilitate the development of new chemical entities based on these scaffolds. Such mechanistic tumor-relevant functional activities have not been described previously and suggest that investigation of FDA approved NSAIDs offer opportunities for repurposing and rapid human translation for the treatment of ovarian cancer. The composite results validate Rho-family GTPases and their downstream effectors as potential prognostic indicators and as therapeutic targets for ovarian cancer.

Citation Format: Yuna Guo, S. Ray Kenney, Elsa Romero, Tudor Oprea, Sarah Adams, Carolyn Muller, Larry Sklar, Tione Buranda, Laurie Hudson, Angela Wandinger-Ness. Selected NSAIDs target GTPases for ovarian cancer therapy. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: From Concept to Clinic; Sep 18-21, 2013; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2013;19(19 Suppl):Abstract nr B81.

Isn't it time for a cadaver skin bank in South Africa?

Improvements in comprehensive burn care, as practiced in dedicated burns units, have reduced mortality and morbidity rates significantly. Strategies deemed most important include the application of fluid resuscitation and nutrition protocols, intensive care and antimicrobial dressings, as well as early excision and grafting. Autografting is limited, however, by availability in very extensive burns, despite the use of expanded (meshed) skin. Alternatives have therefore been required, and deceased donor allograft is considered the gold standard. Fresh allograft use is limited by supply, and legislative and cultural restrictions have significantly influenced availability, despite evidence of its efficacy. This necessitates the establishment of a deceased donor skin bank in South Africa, with a mandate to procure and store allograft for distribution to burns units when required.

Eosinophilic esophagitis in children with esophageal atresia

Eosinophilic esophagitis (EoE) has only rarely been reported in esophageal atresia (EA) patients. A retrospective case analysis of all EA patients born at our center between January 1999 and April 2012 was performed. A total of 113 of patients were identified; 10 patients were excluded as a result of inadequate data. Eighteen patients (17%) were diagnosed with EoE. The average number of eosinophilis was 30/high-power field (HPF) (19/HPF-80/HPF). The median age for diagnosis of EoE was 1 year and 6 months (8 months-8 years and 7 months). Children with EoE had a significantly greater incidence of reflux symptoms, dysphagia, tracheomalacia, and 'hypoxic spells' (P < 0.05). EoE patients also underwent significantly more surgery including fundoplication and aortopexy when compared with those without EoE (P < 0.0001). Although the incidence of gastrostomy was greater in the EoE group (33% vs. 13%), this was not statistically significant. Half of the EoE patients had a coexisting atopic condition at time of diagnosis. The commonest condition was asthma 7/18 (38%) followed by specific food allergy 6/18 (33%). EoE was treated in 11 patients with either swallowed fluticasone or budesonide slurry. All improved clinically. Histologically, five had complete resolution and six had partial improvement. Six children with EoE were treated with acid suppression alone. All improved clinically, and 5/6 had subsequent histological resolution. One child who received acid suppression and an exclusion diet also improved. Seven patients (38%) had an esophageal stricture at time of EoE diagnosis. Five were dilated at time of the initial endoscopy, prior to the diagnosis of EoE being available. Two patients had resolution of their strictures on medical treatment of their EoE alone and did not require further dilatation. EoE was seen in 17% of children with EA in this study. EoE should be considered in EA patients with persistent symptoms on standard reflux treatment, increasing dysphagia, and recurrent strictures.

Tracheostomy in the critically ill: the myth of dead space

Benefits and advantages of tracheostomy have been vigorously debated. There is a lack of consensus as to whether perceived clinical improvement is attributable to fundamental changes in respiratory dynamics. We compare the effect of tracheostomy versus endotracheal tube on dead space, airway resistance and other lung parameters in critically ill ventilated patients. Data collected included patients who were admitted to surgical, burn and neurosurgical intensive care units at the University of North Carolina. Twenty-four intubated patients were included in our analysis with various aetiologies of respiratory failure. Tracheostomy was deemed necessary either for severe neurological devastation or failure to wean from the ventilator. The diameter of the endotracheal tubes ranged from 6-8 mm and the tracheostomy tube diameters were from 6.4-8.9 mm. Internal diameters between endotracheal tube and tracheostomy tubes, ventilator settings and sedation were kept consistent throughout the study. Respiratory parameters were measured using the Respironics' non-invasive cardiac output 2 device (Phillips, Andover, MA) immediately prior to tracheostomy and repeated within 24 hours of tracheostomy. Only two (8%) of the patients had slight improvement (>6% decrease in dead space). The average dead space of endotracheal versus tracheostomy tubes was 41±12.6% and 40±14.6%, respectively (P=0.75). The remaining 22 patients (92%) had no significant change in dead space, compliance or other respiratory parameters. This study shows that there is no significant difference in respiratory mechanics and dead space with a tracheostomy versus endotracheal tube.

Abstract P5-20-05: A Phase 2 trial of RAD 001 and Carboplatin in patients with triple negative metastatic breast cancer

BACKGROUND: RAD001 is an oral mTOR inhibitor that has exhibited activity in breast cancer. Triple negative breast cancer cells are unable to repair double stranded DNA breaks and hence have sensitivity to platinum agents that cause interstrand cross-links. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in at least two different breast cancer cell lines (including ER/PR negative cell lines). We propose that combination RAD001 and carboplatin may have activity in triple-negative breast cancer.

MATERIALS AND METHODS: The primary objective of the study is to determine clinical benefit (complete remission (CR) + partial remission (PR) + stable disease (SD more than 6 months)) and the toxicity of this combination in triple negative metastatic breast cancer who have had 0–3 prior chemotherapy regimens for metastatic disease. Twenty-five subjects were to be entered in this Phase II study. This design has greater than 80% power to test the null hypothesis that the clinical benefit rate is less than or equal to 10% versus the alternative hypothesis that clinical benefit rate is greater than or equal to 30%. Prior carboplatin is allowed. Women with treated brain metastasis are eligible. Secondary objectives are to determine progression free survival and relationship between pretreatment sensitivity (biopsy at baseline) and clinical response (biopsy post 2 cycles) using IHC staining for abundance of key proteins in the Akt-mTOR pathway and their activity using surrogate phosphorylation site-specific antibodies. According to the original study plan, carboplatin AUC 6, was to be given intravenously every three weeks. Five mg of RAD001 was to be given daily with a 3 patient run-in and then 10 mg daily if there were no dose-limiting toxicities. Due to a surprising amount of thrombocytopenia with this combination the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (and no plan to escalate to 10 mg).

RESULTS: 23 patients of a planned 25 have been recruited thus far. Median age is 59. Of the 20 patients assessable for response at this time, there have been 1 CR, 5 PRs, 8 SDs and 6 PDs. One SD was achieved in a patient progressing on single agent Carboplatin at study entry. Median duration of CR+ SD +PR thus far is 13 weeks (range: 6–74 weeks). 5 of 22 patients assessable for toxicity had grade 3/4 thrombocytopenia and 4 patients had grade 3 neutropenia (no febrile neutropenia). 13 out of eighteen patients have had treatment held and/or dose reductions secondary to hematological toxicity, however, since amendment for starting dose of Carboplatin to AUC 4 the regimen has been very well tolerated with only 1 out of eleven patients with grade 3 neutropenia and grade 3 thrombocytopenia. 1 patient suffered from grade 3 dehydration. The estimated clinical benefit rate is 45% (95% confidence interval: 23%, 67%). Median time to progression or death is 85 days from start of treatment.

CONCLUSIONS: Our study has met the primary end point of demonstrating clinical benefit in triple negative metastatic breast cancer. Dose limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. We continue to accrue study subjects at the amended dosing.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-20-05.

RU486 blocks effects of allopregnanolone on the response to restraint stress

These experiments were designed to provide information about the potential involvement of progesterone receptors in the ability of allopregnanolone (3α-hydroxy-5α-pregnan-20-one) to reduce the lordosis-inhibiting effects of restraint stress. Ovariectomized Fischer rats were hormonally primed with 10 μg estradiol benzoate and 4 mg/kg allopregnanolone or vehicle. One hour before allopregnanolone, rats were injected with the progesterone receptor antagonist, RU486 (11β-(4-dimethylamino)phenyl-17β-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one), or vehicle. Four hours after allopregnanolone or vehicle, sexual behavior was examined before and after a 5-min restraint stress. Lordosis behavior of rats primed only with estradiol benzoate declined after the 5 min of restraint while allopregnanolone prevented this decline. RU486 attenuated the ability of allopregnanolone to prevent the restraint-induced decline in lordosis behavior. These findings are consistent with earlier suggestions that progesterone receptors are involved in allopregnanolone's ability to reduce the effects of restraint stress.

Challenging symptoms in children with rare life-limiting conditions: findings from a prospective diary and interview study with families

AIM

The aim was to describe the nature, frequency, severity and management challenges of symptoms in children with two rare life-limiting conditions [Mucopolysaccharide (MPS) and Batten disease].

METHODS

This was an embedded mixed-method study set in the UK between 2009 and 2011. Twenty-six children from 23 families took part. Seventeen children had an MPS condition [MPS III (Sanfilippo) n = 15; MPS I (Hurler) n = 1; MPS IVA (Morquio); n = 1]. Nine children had Batten disease. Prospective data relating to symptoms were collected over 8 weeks using a symptom diary, and qualitative retrospective interviews with families were conducted. Main outcome measures included frequency, severity rating and identification of most challenging symptoms to manage.

RESULTS

The most common and severe symptoms in MPS III were agitation, repetitive behaviours, hyperactivity and disturbed sleep, and in Batten disease were agitation, joint stiffness, secretions, and disturbed sleep. The data highlighted the high prevalence of behavioural symptoms. Distress caused to families by symptoms was not related simply to their occurrence, but to difficulty in management, likelihood of control and extent to which they signalled disease progression and decline.

CONCLUSION

In challenging contrast to the dominant biomedical framing of these rare conditions it was behavioural symptoms, rather than the physical ones, that families documented as most frequent, severe and challenging to manage. The diary developed for this study has potential use in aiding parents and clinicians to document and communicate concerns about symptoms.

Factors influencing fluoxetine-induced sexual dysfunction in female rats

Treatment with selective serotonin reuptake inhibitors, such as fluoxetine, produces sexual side effects with low sexual desire being the most prevalent effect in females. In few studies have preclinical models for such antidepressant-induced sexual dysfunction been fruitful. In the current manuscript, the effects of fluoxetine on multiple measures of female sexual motivation and sexual receptivity were examined. Ovariectomized, Fischer rats were primed with 10 μg estradiol benzoate and 500 μg progesterone. Partner preference, active investigation of the male, and measures of sexual behavior were examined after injection with 15 mg/kg fluoxetine. Factors (pretesting for sexual behavior, size of the test arena, non-contact time with a male) that differ among experiments designed to study antidepressant-induced female rat sexual dysfunction were studied. The male preference ratio was not affected by fluoxetine treatment but active investigation of the male was reduced; lordosis behavior was inhibited and pretesting for sexual receptivity amplified fluoxetine's inhibition; size of the testing arena or non-contact experience with the male had no effect. Regardless of test condition, when given the opportunity to escape from the male, fluoxetine-treated females displayed escape behavior. Measures of male preference and active investigation, but not lordosis behavior, appeared to be affected by fluoxetine's impact on activity. The collective data provided a behavioral profile of fluoxetine-induced sexual dysfunction. These findings reinforce the value of multiple measures when attempting to model antidepressant-induced female sexual dysfunction.

Structure property correlation in lithium borophosphate glasses

To investigate the influence of cation mobility variation due to the mixed glass former effect, 0.45Li(2)O-(0.55-x)P(2)O(5)-xB(2)O(3) glasses (0≤x≤0.55) are studied keeping the molar ratio of Li(2)O/(P(2)O(5)+B(2)O(3)) constant. Addition of B(2)O(3) into lithium phosphate glasses increases the glass transition temperature (T(g)) and number density, decreases the molar volume, and generally renders the glasses more fragile. The glass system has been characterised experimentally by XRD, XPS and impedance studies and studied computationally by constant volume molecular dynamics (MD) simulations and bond valence (BV) method to identify the structural variation with increasing the B(2)O(3) content, its consequence for Li(+) ion mobility, as well as the distribution of bridging and non-bridging oxygen atoms. These studies indicate the increase of P-O-B bonds (up to Y=[B(2)O(3)]/([B(2)O(3)]+[P(2)O(5)])≈0.5 and B-O-B bonds, as well as the decrease of P-O-P bonds and non-bridging oxygens (NBOs) with rising B(2)O(3) content. The system with Y≈0.5 exhibits maximum ionic conductivity, 1.0×10(-7) S cm(-1), with activation energy 0.63 V. Findings are rationalised by a model of structure evolution with varying B(2)O(3) content Y and an empirical model quantifying the effect of the various structural building blocks on the ionic conductivity in this mixed glass former system.

P1-17-07: Phase II Trial of RAD001 Plus Carboplatin in Patients with Triple-Negative Metastatic Breast Cancer

Background: RAD001 is an oral mTOR inhibitor that has exhibited activity in breast cancer. Triple negative breast cancer cells are unable to repair double stranded DNA breaks and hence have sensitivity to platinum agents that cause interstrand cross-links. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in at least two different breast cancer cell lines (including ER/PR negative cell lines). We propose that combination RAD001 and carboplatin may have activity in triple-negative breast cancer.

Methods: The primary objective of the study is to determine clinical benefit (complete remission (CR) + partial remission (PR) + stable disease (SD)) and the toxicity of this combination in women with triple negative metastatic breast cancer who have had 0–3 prior chemotherapy regimens for metastatic disease. Secondary objectives are to determine progression free survival as well as investigating the relationship between pretreatment sensitivity (biopsy at baseline) and clinical response (biopsy post 2 cycles) using IHC staining for abundance of key proteins in the Akt-mTOR pathway and their activity using surrogate phosphorylation site-specific antibodies (Akt and phospho-serine 473, phospho-threonine and phospho-threonine 308 Akt; mTOR and phospho-serine 2448 mTOR; ribosome protein S6 kinase (S6K) and phospho-threonine 378 S6K; 4E-BP1 and phospho-serine 65 4E-BP1). Prior carboplatin is allowed. Women with treated brain metastasis are eligible. According to the original study plan, carboplatin AUC 6, was to be given intravenously every three weeks. Five mg of RAD001 was to be given daily with a 3 patient run-in and then 10 mg daily if there were no dose-limiting toxicities. Due to a unexpected amount of thrombocytopenia with this combination the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (and no plan to escalate to 10 mg).

Results: Fourteen patients of a planned 25 have been recruited thus far. Median age is 58.5. Median number of prior regimens is 2 (0-3). Of the 7 patients assessable for response at this time, there have been 2 PR's and 5 patients with SD. One SD was achieved in a patient progressing on single agent carboplatin at study entry. Median duration of SD + PR is 28.5 weeks (5 patients have ongoing response ranging from 8–46.5 weeks). Five of 8 patients assessable for toxicity had grade 3 or 4 thrombocytopenia and 2 patients had grade 3 neutropenia. No cases of febrile neutropenia were observed. Four patients have required blood transfusion and one patient has required platelet transfusion. All patients have had treatment held and/or dose reductions secondary to hematological toxicity, however, since amended carboplatin dose the regimen has been very well tolerated with only one out of six patients) with grade 3 neutropenia and grade 3 thrombocytopenia. There have been no non-hematological grade 3 or 4 toxicities.

Conclusions: Clinical benefit was observed in all 7 assessable patients. Dose limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. We continue to accrue study subjects at the amended dosing.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-17-07.