Abstract PD2-03: Recurrent functionally diverse in-frame ESR1 gene fusions drive endocrine resistance in breast cancer

Background. We previously reported an alternative ESR1 somatic gain-of-function chromosomal translocation event in a patient presenting with aggressive, endocrine therapy resistant estrogen receptor (ER) positive disease, producing an in-frame fusion gene consisting of N-terminal ESR1 and the C-terminus of the Hippo pathway coactivator YAP1 (ESR1-YAP1). We recently identified another ESR1 fusion through RNA sequencing (RNA-seq) in advanced stage ER+ disease from a chest wall recurrence in a male patient that was refractory to multiple lines of treatment. Two examples of fusions discovered in primary breast cancer samples include ESR1 fused in-frame to C-terminal sequences from NOP2 (ESR1-NOP2), identified in a resistant cohort from a RNA-seq screen focused on 81 primary breast cancers from aromatase inhibitor clinical trials, and a second ESR1 fusion, fused in-frame to the entire coding sequence of POLH (ESR1-POLH), that was identified from RNA-seq analysis of 728 Cancer Genome Atlas breast samples. This current study extends our previous characterization of ESR1-YAP1 by comparing functional and pharmacological properties of these three additional ESR1 gene fusion events of both early stage and advanced breast cancers.

Methods. In vitro and in vivo experiments were conducted to test ESR1 fusions to induce therapeutic resistance, and metastasis. The transcriptional and binding properties of each fusion was also examined. Pharmacological inhibition with Palbociclib, a cyclin-dependent kinase 4/6 inhibitor, was utilized to assess drug sensitivity in ESR1 fusion containing breast cancer cells and in a patient derived xenograft (PDX) model expressing ESR1-YAP1 (WHIM18).

Results. The YAP1 and PCDH11x fusions conferred estrogen-independent and fulvestrant-resistant growth. Immunohistochemistry revealed significantly higher numbers of ER+ cells in lungs of mice xenografted with T47D cells expressing the YAP1 and PCDH11x fusions compared to YFP control, NOP2 and POLH fusions. Results from ChIP-seq and microarray studies suggest that these two fusions promote proliferation and metastasis through genomic action by binding estrogen response elements (ERE) and subsequent gene activation. We thereby define these fusions as “canonical” fusions compared to “non-canonical” NOP2 and POLH fusions, which demonstrated dramatically decreased genomic binding ability. The non-canonical fusions induced genes associated with basal-like breast cancer and promoted HER2, EGFR, and MAPK gene expression signatures in contrast to genes associated with cell cycle/proliferation induced by canonical fusions. The proliferative ability of canonical fusion-containing ER+ cells was inhibited by Palbociclib in a dose-dependent manner. In vivo WHIM18 tumors in mice fed with Palbociclib-containing chow demonstrated significantly reduced tumor volume, growth rate, and weight compared to tumors in mice on control chow.

Conclusions. In-frame ERE activating canonical fusions occur in end-stage drug resistant advanced breast cancer and can be added to ESR1 point mutations as a class of recurrent somatic mutation that may cause acquired resistance. Growth induced by these fusions can be antagonized by Palbociclib and is potentially clinically helpful.

Citation Format: Lei JT, Shao J, Zhang J, Iglesia M, Cao J, Chan DW, He X, Kosaka Y, Schmidt C, Matsunuma R, Haricharan S, Crowder R, Hoog J, Phommaly C, Goncalves R, Ramalho S, Lai W-C, Hampton O, Rogers A, Tobias E, Parikh P, Davies S, Ma C, Suman V, Hunt K, Watson M, Hoadley KA, Thompson A, Chen X, Perou CM, Creighton CJ, Maher C, Ellis MJ. Recurrent functionally diverse in-frame ESR1 gene fusions drive endocrine resistance in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD2-03.

Success Rates in a Diabetes Specialist Nurse-Led Education Programme: Re-setting the Glucostat

Analysis of National Diabetes Audit data from 2011-2012 of newly diagnosed people with type 1 diabetes mellitus (DM) found low initial success rates in much of the UK at 20% on initial training, while an unusually high success rate of 75% achieving target HbA1C<58 mmol/mol (< 7.5%) was found in Cheshire (England average=40.8%). We present a review of the approach taken by the Cheshire Diabetes team in the 12 months following diagnosis. Between 2012 and 2013, 15 consecutive newly diagnosed people with type 1 DM were followed up for 18 months. All received support and advice by community Diabetes Specialist Nurses (DSNs) and Dieticians covering Central and Eastern Cheshire, UK. Mean±SD age at diagnosis was 23±3 years. The period of contact with the DSN service varied from 7-12 weeks. Baseline HbA1C of 99 mmol/mol [11.2%] (95% CI: 86-111 mmol/mol [10.0-12.3%]) declined by ~50% to 49 mmol/mol [6.6%] (41-57 mmol/mol [5.9-7.4%]; F=16.9, p<0.001) at 6 months and did not change between 6-12 months. Of those newly diagnosed with type 1 DM, 84.6% achieved a target HbA1C<58 mmol/mol (<7.5%) and 61.5% met a target<48 mmol/mol (<6.5%). There was no significant weight change during the study. The key elements of this bio-psycho-social approach by the DSN team included providing psychological support, patient engagement, demonstrating positive regard, gaining trust, identifying health-seeking behaviour, providing key decision-making skills and developing a self-management plan. This resulted in improvements in overall glycaemic control well above the national average without untoward weight gain. The UK National Diabetes Audit (2011-2012) in newly diagnosed type 1 diabetics in Cheshire, UK, showed a success rate at 6 months post-diagnosis of 75% achieving a target HbA1C<58 mmol/mol (<7.5%) compared with the national average of 40.8%. Initially thought to be erroneous, these excellent results were confirmed. The approach taken to achieve them is herein described.

Streptococcus grouping latex kits: evaluation of five commercially available examples

This study compares a recently introduced latex agglutination test for the serogrouping of beta-haemolytic streptococci against four internationally used commercial kits. The new kit is Prolex-Blue (Pro-Lab Diagnostics) and the comparators are Streptex (Murex), PathoDx (DPC), Streptococcus Grouping kit (Oxoid) and Prolex-White (Pro-Lab Diagnostics). A total of 302 consecutive clinical isolates are tested against all five kits, following the individual manufacturer's protocol, for both accuracy and speed. In addition, the data produced permits determination of the strengths or weaknesses of the kits against individual serotypes. Prolex-Blue proved to be both accurate and rapid, with a sensitivity of 99% and a specificity of 100%. Furthermore, average time to agglutination was substantially less than achieved by three of the other four kits evaluated.

Compositional analysis of excavated landfill samples and the determination of residual biogas potential of the organic fraction

The objectives of this study were to assess the biogas potential of landfilled materials and to further validate the suitability of the enzymatic hydrolysis test EHT as a valuable alternative to substitute the standardised test currently in use (BMP). Both tests were applied to a range of landfill waste samples. The waste composition and volatile solids content (VS) profile together with the BMP test results showed that the biogas potential of the waste samples was directly related to their VS content, as expected. The positive correlation between the VS and the BMP test (r=0.67) suggests that the first could be used as a primary indicator of biogas potential of waste samples. Nevertheless, it should be validated against the BMP test because, occasionally, the VS content does not equate to the biogas production. This was mainly due to the paper content of the samples which also correlates positively (r=0.77) with the BMP biogas production. The EHT results showed a higher correlation with the BMP test (r=0.91) than in previous studies which used a wider mixture of enzymes containing cellulase, hemicellulase and carbohydrase. This finding positions the EHT as a quick assessing method for the biodegradability of waste samples in future sample regimes.

Evaluating leachate recirculation with cellulase addition to enhance waste biostabilisation and landfill gas production

The effect of leachate recirculation with cellulase augmentation on municipal solid waste (MSW) biostabilisation and landfill gas production was investigated using batch bioreactors to determine the optimal conditions of moisture content, temperature and nutrients. Experimentation was thereafter scaled-up in 7L bioreactors. Three conditions were tested including (1) leachate recirculation only, (2) leachate recirculation with enzyme augmentation and (3) no leachate recirculation (control). Cumulative biogas production of the batch tests indicated that there was little difference between the leachate and control test conditions, producing on average 0.043m(3)biogaskg(-1) waste. However the addition of cellulase at 15×10(6)Utonne(-1) waste doubled the biogas production (0.074m(3)biogaskg(-1) waste). Similar trend was observed with the bioreactors. Cellulase addition also resulted in the highest COD reduction in both the waste and the leachate samples (47% and 42% COD reduction, respectively). In both cases, the quantity of biogas produced was closer to the lower value of theoretical and data-based biogas prediction indicators (0.05-0.4m(3)biogaskg(-1) waste). This was likely due to a high concentration of heavy metals present in the leachate, in particular Cr and Mn, which are known to be toxic to methanogens. The cost-benefit analysis (CBA) based on the settings of the study (cellulase concentration of 15×10(6)Utonne(-1) waste) showed that leachate bioaugmentation using cellulase is economically viable, with a net benefit of approximately €12.1million on a 5Mt mixed waste landfill.

Information technology in nurse education: a multimedia approach to teaching biological sciences

The School of Health Science at the University of Wales Swansea offers programmes for nurses and other healthcare professionals ranging from pre-registration nursing to post-doctoral studies. Biological science is an important component of the pre-registration programme, the delivery of which has proved to be problematic. Research conducted by the school has identified that a more innovative approach to teaching and learning this subject is required.

There is a growing body of evidence that Multimedia Learning (MML) can enhance the quality of education, supporting or replacing the traditional didactic lecture and providing the student with information and standards of presentation that have never before been available. With this in mind, and responding to the research findings, the school has made a substantial investment in multimedia technology. We have now embarked on a programme to produce and deliver a biological science module for nursing students. If the evaluation of the programme demonstrates sustainable improvements in learning and offers enhanced quality in the delivery of programmes, it is the intention to extrapolate the biological science project to other curriculum subjects.

Equitable tuberculosis care in the North West of England: analysis of tuberculosis cohort review data

BACKGROUND: In the United Kingdom, tuberculosis (TB) predominantly affects the most deprived populations, yet the extent to which deprivation affects TB care outcomes is unknown.

METHODS: Since 2011, the North West TB Cohort Audit collaboration has undertaken quarterly reviews of outcomes against consensus-defined care standard indicators for all individuals notified with TB. We investigated associations between adverse TB care outcomes and Index of Multiple Deprivation (IMD) 2010 scores measured at lower super output area of residence using logistic regression models.

RESULTS: Of 1831 individuals notified with TB between 2011 and 2014, 62% (1131/1831) came from the most deprived national quintile areas. In single variable analysis, greater deprivation was significantly associated with increased likelihood of the completion of a standardised risk assessment (OR 2.99, 95%CI 5.27–19.65) and offer of a human immunodeficiency virus test (OR 1.72, 95%CI 1.10–2.62). In multivariable analysis, there were no significant associations.

CONCLUSIONS: TB patients in the most deprived areas had similar care indicators across a range of standards to those of individuals living in the more affluent areas, suggesting that the delivery of TB care in the North West of England is equitable. The extent to which the cohort review process contributes to, and sustains, this standard of care deserves further study.

Preimplant Normothermic Liver Perfusion of a Suboptimal Liver Donated After Circulatory Death

Livers retrieved after circulatory death are associated with an increased incidence of primary nonfunction, early allograft dysfunction, and biliary strictures. The authors report a case of preimplant normothermic perfusion of a suboptimal liver from a 57-year-old donor after circulatory death who had been hospitalized for 9 days; predonation alanine transaminase level was 63 IU/L, and the period from withdrawal of life-supporting treatment to circulatory arrest was 150 minutes. After 5 hours of static cold storage, the liver was subject to normothermic machine perfusion with a plasma-free red cell-based perfusate. Perfusate lactate level fell from 7.2 to 0.3 mmol/L within 74 minutes of ex situ perfusion, at which point perfusate alanine transaminase level was 1152 IU/L and urea concentration was 9.4 mmol/L. After 132 minutes, normothermic perfusion was stopped and implantation begun. After transplantation, the patient made an uneventful recovery and was discharged on day 8; liver biochemistry was normal by day 19 and has remained normal thereafter. Donor common bile duct excised at implantation showed preservation of peribiliary glands, and cholangiography 6 months posttransplantation showed no evidence of cholangiopathy. Preimplant ex situ normothermic perfusion of the liver appears to be a promising way to evaluate a marginal liver before transplantation and may modify the response to ischemia.

Ecological conditions of ponds situated on blast furnace slag deposits located in South Gare Site of Special Scientific Interest (SSSI), Teesside, UK

Slag, a by-product from the iron and steel industry, has a range of applications within construction and is used in wastewater treatment. Historically considered a waste material, little consideration was given to the environmental impacts of its disposal. South Gare (a Site of Special Scientific Interest) located at the mouth of the Tees estuary, UK, formed on slag deposits used to create a sea wall and make the land behind permanent. Over time, ponds formed in depressions with the water chemistry, being significantly impacted by the slag deposits. Calcium levels reached 504 mg/L, nitrate 49.0 mg/L and sulphate 1,698 mg/L. These levels were also reflected in the composition of the sediment. pH (5.10-9.90) and electrical conductivity (2,710-3,598 µS/cm) were variable but often notably high. Pb, Cu and Cd were not present within the water, whilst Zn ranged from 0.027 to 0.37 mg/L. Heavy metal levels were higher in surface sediments. Zinc was most dominant (174.3-1,310.2 mg/L) followed by Pb (9.9-431 mg/L), Cu (8.4-41.8 mg/L) and Cd (0.4-1.1 mg/L). A sediment core provided a historical overview of the ponds. The ponds were unfavourable for aquatic biodiversity and unsuitable for drinking water abstraction.

Effects of submarine power transmission cables on a glass sponge reef and associated megafaunal community

We examined the effects of submarine power transmission cable installation and operation on glass sponge reef condition and associated megafauna. Video and still imagery were collected using a Remotely Operated Vehicle twice a year for 4 years following cable installation. The effects of cables on glass sponges were assessed by comparing sponge cover along fixed transects and at marked index sites. Megafauna counts along transects were used to explore the effects on associated community. We found no evidence of cable movement across the sponge reef surface. Live sponge cover was found to be consistently lower along cable transects and at cable index sites compared to controls. Live sponge cover was the lowest (55 ± 1.1% decrease) at cable index sites 1.5 years after installation and recovered to 85 ± 30.6% of the original size over the following 2 years. Our data suggest 100% glass sponge mortality along the direct cable footprint and 15% mortality in the surrounding 1.5 m corridor 3.5 years after cable installation. Growth rate of a new glass sponge was 1 and 3 cm/year in first and second year, respectively, and appeared to be seasonal. We observed a diverse megafaunal community with representatives from 7 phyla and 14 classes. Total megafauna, spot prawn, and other Arthropoda abundances were slightly lower along cable transects although the effect of cable presence was not statistically significant. The following measures could be taken to reduce the amount of damage to glass sponge reefs and associated fauna: routing the cable around reefs, whenever possible, minimizing cable movement across the surface of the reef at installation and routine operation, and assessing potential damage to glass sponges prior to decommissioning.

Let's go outside: using photography to explore values and culture in mental health nursing

Creative and imaginative approaches to mental healthcare education are known to help students explore emotions, empathy and others' experiences, as well as address ambivalence and ambiguity. Very few studies in mental health nursing education specifically utilise photography as a participatory pedagogic tool, with even fewer utilising photography to explore understandings of culture, values and diversity. Photography makes visible complex, collaborative forms of learning and previously unidentified, unarticulated ideas about culture and values. Photography as a critical pedagogic method helps develop critical, politicized understandings of culture and values. Increasing culturally diverse populations means complex and conflicting values have become a common feature in mental health nursing. In education the need to critically examine such topics necessitates creative and engaging pedagogy, and visual methods are readily acknowledged as such. Yet while many studies advocate and demonstrate the value of art-based methods in student learning, very few studies in mental health nursing specifically utilize photography as a participatory pedagogic tool, and fewer still use photography to explore understandings of culture, values and diversity. In this paper, we discuss a qualitative study where mental health nursing students used photography to create images in order to explore their own and often dominant culture and attendant values. Findings suggest that photography makes visible situated, relational and collaborative learning, and surfaces previously unidentified, unarticulated ideas about culture and values. These practices mimic important processes central to mental health nursing practice and contemporaneous understandings of diverse cultures. We argue that photography provides an important resource with which to unearth subjugated knowledge, promote critical understandings of culture and values, and thereby help address inequalities in mental health care.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

A retrospective 15-year review: survival advantage after switching to sirolimus in hepatitis C virus infected liver graft recipients

BACKGROUND

The use of sirolimus-based immune suppression in liver transplantation, particularly in hepatitis C virus (HCV)-infected recipients, remains contentious. There is some evidence that sirolimus retards hepatic fibrosis, is renal sparing and may be of benefit in preventing hepatocellular carcinoma (HCC) recurrence. Sirolimus has not been adopted by many transplant centres because of persistent concerns regarding an increased risk of hepatic artery thrombosis, graft loss and death with de novo sirolimus.

AIM

To review the impact of switching to sirolimus monotherapy in HCV-infected liver recipients with respect to survival, graft loss and hepatic fibrosis.

METHODS

A retrospective review of 190 patients from a single centre undergoing first liver transplantation for HCV over 15 years. 113 patients were switched from calcineurin inhibitor (CNI)-based therapy to low-dose sirolimus monotherapy at a median of 15 months after transplantation for HCV-related fibrosis (72%), renal impairment (14%) or high-risk HCC (5%).

RESULTS

Patients switched to sirolimus had improved survival (P < 0.001) and slower progression to cirrhosis (P = 0.001). In patients with HCC (n = 91), sirolimus duration rather than strategy was an independent predictor of survival (P = 0.001) and extended time to HCC recurrence (33 vs. 16 months). Patients switched for renal dysfunction showed improvement in serum creatinine (140-108 μmol/L, P = 0.001). Those remaining on CNI-therapy were more likely to develop post-transplant diabetes (P = 0.03).

CONCLUSION

These data suggest selective switching to low-dose sirolimus monotherapy in HCV-positive liver recipients improves clinical outcome.