Outcomes in lung cancer: An experience from routine tertiary care setting

BACKGROUND

The aim of this study was to establish characteristics of lung cancer patients diagnosed at a tertiary care hospital in Bangalore.

METHODS

The retrospective study was undertaken comprising of 202 patients diagnosed of advanced lung cancer in a tertiary care setting. Data was analyzed to identify patients' characteristics, smoking history, tumor histology, stage of the disease, treatment received, and survival rates.

RESULTS

Among the 202 patients diagnosed, 134 were males, and 68 were females. Tumor histology testing revealed that 168 patients had adenocarcinoma, 24 patients had squamous carcinoma, 5 patients had small cell carcinoma, and 5 patients were poorly differentiated carcinoma. Among the patients of adenocarcinoma, complete response, partial response (PR), stable disease, and progressive disease (PD) were seen in 0.6%, 52%, 17%, and 23.2% of the patients respectively. The median progression-free survival (PFS) for first-line treatment was 6.5 months; the highest PFS was seen with nab-paclitaxel/platinum combination. The mean overall survival was 11.7 months and the highest OS of 12.3 months with gefitinib therapy. In the squamous subset of patients, PR was observed in fourteen patients, of which five patients were treated with nab-paclitaxel/platinum. The mean overall survival of 10.5 months and mean PFS was 6.2 months with the highest PFS of 6.8 months were seen with weekly nab-paclitaxel. Among the small cell lung cancer patients, nine were treated with etoposide/platinum regimen with a compliance of 6 cycles. Three patients had a PR, and one had a PD on etoposide/platinum regimen. The mean overall survival in these patients was 4.6 months.

Observation of pseudogap in MgB2

We investigate the electronic structure of a specially prepared highly dense conventional high temperature superconductor, MgB₂, employing high resolution photoemission spectroscopy. The spectral evolution close to the Fermi energy is commensurate to BCS descriptions as expected. However, the spectra in the wider energy range reveal the emergence of a pseudogap much above the superconducting transition temperature indicating an apparent departure from the BCS scenario. The energy scale of the pseudogap is comparable to the energy of the [Formula: see text] phonon mode responsible for superconductivity in MgB₂ and the pseudogap can be attributed to the effect of electron-phonon coupling on the electronic structure. These results reveal a scenario of the emergence of the superconducting gap within an electron-phonon coupling induced pseudogap and have significant implications in the study of high temperature superconductors.

Isolation and evolutionary analysis of Australasian topotype of bluetongue virus serotype 4 from India

Bluetongue (BT) is a Culicoides-borne disease caused by several serotypes of bluetongue virus (BTV). Similar to other insect-borne viral diseases, distribution of BT is limited to distribution of Culicoides species competent to transmit BTV. In the tropics, vector activity is almost year long, and hence, the disease is endemic, with the circulation of several serotypes of BTV, whereas in temperate areas, seasonal incursions of a limited number of serotypes of BTV from neighbouring tropical areas are observed. Although BTV is endemic in all the three major tropical regions (parts of Africa, America and Asia) of the world, the distribution of serotypes is not alike. Apart from serological diversity, geography-based diversity of BTV genome has been observed, and this is the basis for proposal of topotypes. However, evolution of these topotypes is not well understood. In this study, we report the isolation and characterization of several BTV-4 isolates from India. These isolates are distinct from BTV-4 isolates from other geographical regions. Analysis of available BTV seg-2 sequences indicated that the Australasian BTV-4 diverged from African viruses around 3,500 years ago, whereas the American viruses diverged relatively recently (1,684 CE). Unlike Australasia and America, BTV-4 strains of the Mediterranean area evolved through several independent incursions. We speculate that independent evolution of BTV in different geographical areas over long periods of time might have led to the diversity observed in the current virus population.

Outcomes following osteosynthesis of periprosthetic hip fractures around cemented tapered polished stems

We retrospectively reviewed outcomes of 79 patients with periprosthetic hip fractures around cemented tapered polished stem (CTPS) implants treated with osteosynthesis between January 1997 and July 2011. All patients underwent open reduction and fixation using a broad dynamic compression plate (DCP). Seventy two (91%) of fractures united. There were seven (9%) non-unions with failure of metal work, three (4%) as a result of infection and four (5%) due to mechanical failure. Significant subsidence (>5mm) of the implant was seen in seven (9%) of cases. Ten (13%) cases developed post-operative infection. Non-anatomic reduction and infection were identified as predictors of poor outcome. This is the largest series of a very specific group of periprosthetic fractures treated with osteosynthesis. Open reduction internal fixation with a broad dynamic compression plate for patients with periprosthetic hip fractures around the tip of cemented tapered polished stems is a suitable treatment provided there is no bone loss and the fracture can be precisely, anatomically, reduced and adequately fixed.

Genomic Alterations and Outcomes with VEGF-Targeted Therapy in Patients with Clear Cell Renal Cell Carcinoma

Background: Mutations in VHL, PBRM1, SETD2, BAP1, and KDM5C are common in clear cell renal cell carcinoma (ccRCC), and presence of certain mutations has been associated with outcomes in patients with non-metastatic disease. Limited information is available regarding the correlation between genomic alterations and outcomes in patients with metastatic disease, including response to VEGF-targeted therapy.

Objective: To explore correlations between mutational profiles and cancer-specific outcomes, including response to standard VEGF-targeted agents, in patients with metastatic cc RCC.

Methods: A retrospective review of 105 patients with metastatic ccRCC who had received systemic therapy and had targeted next-generation sequencing of tumors was conducted. Genomic alterations were correlated to outcomes, including overall survival and time to treatment failure to VEGF-targeted therapy.

Results: The most frequent mutations were detected in VHL (83%), PBRM1 (51%), SETD2 (35%), BAP1 (24%), KDM5C (16%), and TERT (14%). Time to treatment failure with VEGF-targeted therapy differed significantly by PBRM1 mutation status (p = 0.01, median 12.0 months for MT versus 6.9 months for WT) and BAP1 mutation status (p = 0.01, median 6.4 months for MT versus 11.0 months for WT). Shorter overall survival was associated with TERT mutations (p = 0.03, median 29.6 months for MT versus 52.6 months for WT) or BAP1 mutations (p = 0.02, median 28.7 months for MT versus not reached for WT).

Conclusions: Genomic alterations in ccRCC tumors have prognostic implications in patients with metastatic disease. BAP1 and TERT promoter mutations may be present in higher frequency than previously thought, and based on this data, deserve further study for their association with poor prognosis.

Assessing stress responses to atmospheric cold plasma exposure using Escherichia coli knock-out mutants

AIMS

This study investigated the effect of atmospheric cold plasma (ACP) exposure-induced stress on microbial inactivation patterns and the regulation of genes involved in the microbial stress response in conjunction with key processing parameters of exposure time and post-treatment storage time.

METHODS AND RESULTS

Cell suspensions of Escherichia coli BW 25113 and its isogenic knock-out mutants in rpoS, soxR, soxS, oxyR and dnaK genes were treated with high-voltage ACP in a sealed package for 1, 3 and 5 min followed by 0-, 1- and 24-h post-treatment storage. Reactive oxygen species (ROS) densities and colony formation were determined. ΔrpoS strain showed higher microbial reduction and greater cell permeability than other mutants, while ΔoxyR only showed this effect after 5 min of treatment. With increased post-treatment storage time, ΔsoxS and ΔsoxR had increased sensitivity and resistance respectively. ΔdnaK cell suspensions had much higher ROS than other strains and showed increased sensitivity with 24 h post-treatment storage.

CONCLUSIONS

RpoS and oxyR genes have both short-term and long-term regulatory effects under plasma stress. However, knocking out dnaK gene had an immediate response on ROS scavenging and long-term repairing mechanisms. ΔsoxR and ΔsoxS had different responses to ACP treatment with the increase in post-treatment time in relation to clearance of reactive species implying the different characteristics and functions as subunits.

SIGNIFICANCE AND IMPACT OF THE STUDY

By comparing the response of mutants under ACP exposure to key processing parameters, the mechanism of microbial inactivation was partly revealed with respect to cellular regulation and repairing genes.

Can we predict which dysplastic hips will require acetabular augmentation during total hip arthroplasty based on pre-operative radiographs?

AIMS

The purpose of this study was to evaluate whether an innovative templating technique could predict the need for acetabular augmentation during primary total hip arthroplasty for patients with dysplastic hips.

PATIENTS AND METHODS

We developed a simple templating technique to estimate acetabular component coverage at total hip arthroplasty, the True Cup: False Cup (TC:FC) ratio. We reviewed all patients with dysplastic hips who underwent primary total hip arthroplasty between 2005 and 2012. Traditional radiological methods of assessing the degree of acetabular dysplasia (Sharp's angle, Tönnis angle, centre-edge angle) as well as the TC:FC ratio were measured from the pre-operative radiographs. A comparison of augmented and non-augmented hips was undertaken to determine any difference in pre-operative radiological indices between the two cohorts. The intra- and inter-observer reliability for all radiological indices used in the study were also calculated.

RESULTS

Of the 128 cases reviewed, 33 (26%) needed acetabular augmentation. We found no difference in the median Sharp's angle (p = 0.10), Tönnis angle (p = 0.28), or centre-edge angle (p = 0.07) between the two groups. A lower TC:FC ratio was observed in the augmented group compared with the non-augmented group (median = 0.66 versus 0.88, p < 0.001). Intra-observer reliability was found to be high for all radiological indices analysed (interclass correlation coefficient (ICC) > 0.7). However, inter-observer reliability was more variable and was only high for the TC: FC ratio (ICC > 0.7).

CONCLUSION

The TC: FC ratio gives an accurate estimate of acetabular component coverage. It can help predict which dysplastic hips are likely to need acetabular augmentation at primary total hip arthroplasty. It has high intra- and inter-observer reliability. Cite this article: Bone Joint J 2017;99-B:445-50.

Abstract P4-07-10: Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers

Background: MicroRNA mediated molecular alterations are involved in the initiation and progression of cancer. Altered expression of multiple microRNAs is associated with endocrine resistance in hormone receptor positive HER2 negative (HR+/HER2-ve) cancer. The role of miR-221 in inducing epithelial to mesenchymal transition (EMT) is well documented especially in cell line model systems. However, the detailed mechanism of specific microRNAs in intrinsic and acquired resistance to endocrine therapy needs to be worked out. In addition, more needs to be done in the documentation of these mechanisms in human breast cancer specimens with complete clinical documentation and long-term follow-up. In this study, we have evaluated the clinical significance of miR-221 and its mechanistic role in EMT using human specimens and cell line models.

Materials and Methods: Formalin fixed paraffin embedded tumor from 129 HR+/HER2-ve breast cancer patients with a median follow up of 63 months were used for estimation of miR-221 by quantitative real time PCR. Expression levels of genes which are direct targets of miR-221 and related genes in EMT were analysed from these tumors. Survival between miR-221 high and low groups was compared by Kaplan Meier survival curves and prognostic relevance was estimated by Cox proportional hazard model.

Cell line experiments to investigate the role of miR-221 in inducing EMT through integrin β6 are underway in both wild type and tamoxifen resistant MCF-7 cell lines (A gift from Prof Ben Ho Park, Johns Hopkins University School of Medicine).

Results: A significant elevated level of miR-221 was observed in small proportion (14%) of HR+/HER2-ve tumors. miR-221 expression had an inverse correlation with both ER protein and ESR1 mRNA levels within HR+/HER2-ve tumors. Tumors with high levels of miR-221 showed significantly higher expression of integrin β6 which is a robust marker of EMT. Patients with high expression of miR-221 had a poorer survival in Kaplan Meier analysis.

Results of interrogation of EMT mediated through integrin related pathways involving miR-221 in cell line models will be presented.

Discussion: The association between miR-221 and integrin β6 in HR+/HER2-ve breast cancer with endocrine resistance suggests a potential link between an epigenetic regulator and a mediator of tumor-stromal interaction. The other mediators involved in this pathway are being investigated. miR-221 could be potentially used as a marker for identification of a poor prognostic subtype within HR+/HER2-ve breast cancers.

Citation Format: Prabhu JS, Kaul R, Korlimarla A, Desai K, Gangadharan C, Rajarajan S, Nair MG, Alexander A, Kaluve R, Manjunath S, Correa M, Prasad MSN, Patil S, Srinath BS, Sridhar TS. Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers [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 P4-07-10.

Abstract P1-09-14: Breast carcinoma with 21-gene recurrence score lower than 18: Rate of distant metastases in a large series with clinical follow-up

Background: The 21-gene recurrence score (RS) estimates the likelihood of distant recurrence and the benefit from chemotherapy in patients with early-stage node-negative, estrogen receptor (ER)-positive, HER2-negative breast carcinoma. The use of the assay resulted in a substantial reduction in adjuvant chemotherapy usage. In this study, we reviewed the outcome of patients with node-negative, ER+/HER2- breast cancer and low recurrence score treated at our center to further verify the prognostic value of the assay.

Design: We identified breast cancer patients treated at our center between 09/2008 and 08/2013 with ER-positive, HER2-negative breast cancer and known RS. We reviewed clinicopathological characteristics, RS, treatment and outcome data. The Institutional Review Board approved the study.

Results: We identified 1406 consecutive patients with early stage node negative ER+/HER2- breast cancer and low RS [RS 0-10: 510 (36%), RS 11-17: 896 (64%)] in the study period. The median age at breast cancer diagnosis was 56 years (range 22-90). Sixty-three (4%) patients were &lt;40 years old at breast cancer diagnosis. A total of 1362 (97%) patients received endocrine therapy, and 170 (12%) received chemotherapy. The median follow up time was 46 months (range 1-85). Six (0.4%) of the 1406 patients developed biopsy proven distant metastases within 5 years of breast cancer diagnosis, 5 of which were in the RS 11-17 group (Table 1). Three of the 5 patients with RS 11-17 and distant metastases were younger than 40 years old at breast cancer diagnosis. In the RS 11-17 group, the absolute incidence of distant metastases among patients with breast cancer diagnosed at age younger than 40 years old is 7.1% (3/42), whereas the absolute incidence of distant metastases among patients ≥40 years is 0.2% (2/854).

Conclusion: Our results suggest that young age (&lt;40 years old) might be a negative prognostic factor even in patients with low RS. Analysis of data from other studies is necessary to further validate this observation.

Table 1. Clinicopathologic characteristics of the 6 patients with ER-positive, HER2-negative, node-negative breast carcinoma of recurrence score &lt;18 who developed distant metastasisPatients#1#2#3#4#5#6Age at diagnosis (years)505437713839Family history of breast/ ovarian cancerNoYesNoNoNoYesPersonal history of breast carcinomaNoIpsilateral DCISNoIpsilateral DCISNoNoTumor typeILCIDCIDCIDCIDCIDCTumor size (cm)2.11.32.72.31.62.1Tumor Grade222223LVINoNoNoNoYesNoER (%)909595959595PR (%)30585757595Oncotype DX RS51212131417SurgeryBTMTMBTMBCSBCSBTMRadiationNoNoNoYesYesNoEndocrine therapyYesYesYesYesNoYesChemoNoNoCMFNoNoNoTime interval to metastasis (months)584125204812Site of metastasisBoneMultipleLungMultipleMultipleBoneFollow-up (months)725359647142SurvivalAWDAWDAWDDODAWDAWDAbbreviations: RS, recurrence score; ILC, invasive lobular carcinoma; IDC, invasive ductal carcinoma; LVI, lymphovascular invasion; BTM, bilateral total mastectomy; TM, total mastectomy; BCS, breast conserving surgery; CMF, cyclofosphamide, metotrexate and 5-fluorouracil. AWD, alive with disease; DOD, died of disease.

Citation Format: Wen HY, Krystel-¬Whittemore M, Patil S, Pareja F, Bowser ZL, Dickler M, Norton L, Morrow M, Hudis C, Brogi E. Breast carcinoma with 21-gene recurrence score lower than 18: Rate of distant metastases in a large series with clinical follow-up [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 P1-09-14.

Abstract P2-08-05: Phase I/II trial of palbociclib in combination with bicalutamide for the treatment of androgen receptor (AR)+ metastatic breast cancer (MBC)

This abstract was withdrawn by the authors.

Abstract P3-13-07: Are there patients with T1-T2, node-negative breast cancer who are high-risk for locoregional recurrence?

Background: Indications for post-mastectomy radiotherapy (PMRT) in T1-T2, node negative (N0) breast cancer patients with “high-risk” features are controversial based on lack of consensus as to what constitutes “high-risk”, and variable results of small retrospective studies. The EORTC 22922 and MA20 trials reporting improved 10-year disease-free survival with nodal irradiation included high-risk N0 patients but these patients were not analyzed separately and did not receive modern systemic therapy. We sought to evaluate long-term locoregional control in T1-T2N0 patients with high-risk features undergoing mastectomy in the contemporary era.

Methods: We retrospectively identified patients with T1-T2N0 breast cancer with ≥1 high-risk feature treated with mastectomy from 1/2006-12/2011. High-risk features were defined as age &lt;40 years, multifocal/multicentric disease, lymphovascular invasion (LVI), medial or central tumor location, and high nuclear grade. The primary outcome of interest was rate of LRR.

Results: Among 672 patients meeting inclusion criteria, 187 (28%) had 1 risk factor: 21 (3%) were age &lt;40 years, 132 (20%) were multifocal/multicentric, and 34 (5%) had LVI; 449 (67%) patients had ≥2 high-risk features, and 36 patients with unknown grade were excluded from risk analysis. PMRT was received by only 15 (2%) patients. Clinicopathologic characteristics of the 657 patients treated without PMRT are shown in Table 1.

Table 1: Clinicopathologic characteristics, n = 657 Median (Range)Age, years49 (24-89)Tumor size, cm1.4 (&lt;0.1-5.0) n (%)Ductal histology566 (86%)High nuclear grade*266 (40%)LVI232 (35%)Multifocal/multicentric447 (68%)Medial/central tumor226 (34%)Receptor status** ER+/HER2-438 (67%)HER2+123 (19%)ER-/HER2-70 (11%) n (%)Rate of LRR# of risk factors*  1183 (28%)3.8%2265 (40%)5.3%3143 (22%)4.9%4 or 532 (5%)9.4%*Unknown grade in 34 cases, excluded from risk analysis **Unknown receptor status in 26 cases

Sentinel node biopsy alone was performed in 98% of these patients. A median of 4 lymph nodes were retrieved (range 1-15). Adjuvant systemic therapy was received by 86% of patients. At median 5.6 years of follow-up, overall LRR rate was 4.7% (n = 31), with the majority (55%) of events involving the chest wall. Increasing tumor size was associated with LRR (HR 1.70, 95% CI 1.26–2.29, p = 0.006), while age, histology, grade, subtype, LVI, multifocality/multicentricity, and tumor location were not (all p &gt; 0.05). Although rate of LRR increased from 3.8% to 9.4% with 1 vs. ≥4 high-risk features, a comparison of 1 vs. 2 vs. 3 vs. ≥4 risk factors was not significant by Kaplan-Meier estimation (p = 0.54).

Conclusions: A low LRR rate of 4.7% was seen in this large unselected cohort of T1-T2N0 cancers with "high-risk" features treated by mastectomy and systemic therapy without PMRT. While increasing tumor size was predictive, other features did not confer a higher risk of LRR either independently or together, and do not by themselves mandate the use of PMRT in this population.

Citation Format: Mamtani A, Patil S, Stempel M, Morrow M. Are there patients with T1-T2, node-negative breast cancer who are high-risk for locoregional recurrence? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-07.

Abstract P6-10-05: A pilot study of radiation (RT) and CTLA4-mediated checkpoint blockade with tremelimumab for the treatment of breast cancer brain metastases (BCBM)

This abstract was withdrawn by the authors.

Chondrosarcoma of Small Bones of the Hand

A clinicopathological review of 23 patients (mean age, 67 years; range, 42–85 years) with chondrosarcoma of the bones of the hand was done. The mean follow up was 8.5 years. Eleven patients presented with a progressive painless swelling, 26% having had symptoms for over 10 years. The proximal phalanx was the commonest site. Initial clinical misdiagnosis as ganglion, bursa, gout, rheumatoid arthritis and a cyst occurred in five patients. Radiologically most lesions showed bone expansion, cortical destruction and soft-tissue extension. The majority was of high histologic grade (Evan’s grade 2 & 3) with extensive myxoid areas. Five out of eight patients who were originally treated by curettage or excision had local recurrences compared to none treated by ray resection or amputation of phalanx ( P=0.002). None had metastases. The low risk of metastases despite the high histologic grade indicates that chondrosarcomas of the hand behave differently from chondrosarcomas elsewhere.

Everolimus plus octreotide long-acting repeatable in advanced neuroendocrine tumors in the routine tertiary cancer care setting: An Indian experience

BACKGROUND

Neuroendocrine tumors (NETs) are rare, heterogeneous, indolent tumors that are relatively insensitive to systemic chemotherapy. Therapeutic strategies for NETs broadly include somatostatin analogs, antiangiogenic therapy, and most recently, mammalian target of rapamycin inhibition. Combination therapy has shown promising antitumor activity and good tolerability in the randomized phase III trials.

AIM

The aim was to evaluate the safety and efficacy of Everolimus plus Octreotide long-acting repeatable (LAR) in patients with advanced NETs in the routine tertiary cancer care setting in India in this postapproval, noninterventional trial.

PATIENTS AND METHODS

Patients presenting to selected centers between 2011 and 2013 with histologically confirmed low-, intermediate- or high-grade advanced NETs who may have had prior exposure to cytotoxic chemotherapy (≤2 lines) were treated with oral Everolimus (10 mg/day) plus intramuscular Octreotide LAR (30 mg once every 28 days) until disease progression or unacceptable toxicity was seen. Patients were evaluated every 3 months for a response to therapy as per Response Evaluation Criteria in Solid Tumors.

RESULTS

Everolimus plus Octreotide LAR was associated with a clinical benefit rate of 69% (best evaluable responses: Stable disease [SD] in 10 patients [63%], partial response in 1 patient [6%]). The average duration of therapy was 4.8 cycles, and 3 (17%) patients continued therapy for ≥12 cycles (all achieved SD). The therapy was found to be well-tolerated in all patients.

CONCLUSIONS

Everolimus plus Octreotide LAR appears to be safe and efficacious in patients with advanced NETs who may have had prior exposure to chemotherapy - a finding consistent with recently conducted major trials.

Genomic profiling in a homogeneous molecular subtype of non-small cell lung cancer: An effort to explore new drug targets

BACKGROUND

Patients' who are positive for kinase domain activating mutations in epidermal growth factor receptor (EGFR) gene, constitute 30-40% of non-small cell lung cancer (NSCLC), and are suitable candidates for Tyrosine Kinase Inhibitor based targeted/personalized therapy. In EGFR non-mutated subset, 8-10% that show molecular abnormalities such as EML4-ALK, ROS1-ALK, KIP4-ALK, may also derive the benefit of targeted therapy. However, 40% of NSCLC belong to a grey zone of tumours that are negative for the clinically approved biomarkers for personalized therapy. This pilot study aims to identify and classify molecular subtypes of this group to address the un-met need for new drug targets in this category. Here we screened for known/novel oncogenic driver mutations using a 46 gene Ampliseq Panel V1.0 that includes Ser/Thr/Tyr kinases, transcription factors and tumor suppressors.

METHODS

NSCLC with tumor burden of at least 40% on histopathology were screened for 29 somatic mutations in the EGFR kinase domain by real-time polymerase chain reaction methods. 20 cases which were EGFR non-mutated for TK domain mutations were included in this study. DNA Quality was verified from each of the 20 cases by fluorimeter, pooled and subjected to targeted re-sequencing in the Ion Torrent platform. Torrent Suite software was used for next generation sequencing raw data processing and variant calling.

RESULTS

The clinical relevance and pathological role of all the mutations/variants that include SNPs and Indels was assessed using polyphen-2/SIFT/PROVEAN/mutation assessor structure function prediction programs. There were 10 pathogenic mutations in six different oncogenes for which annotation was available in the COSMIC database; C420R mutation in PIK3CA, Q472H mutation in vascular endothelial growth factor receptor 2 (VEGFR2) (KDR), C630W and C634R in RET, K367M mutation in fibroblast growth factor receptor 2 (FGFR2), G12C in KRAS and 4 pathogenic mutations in TP53 in the DNA binding domain (E285K, R213L, R175H, V173G).

CONCLUSION

Results suggest, a potential role for PIK3CA, VEGFR2, RET and FGFR2 as therapeutic targets in EGFR non-mutated NSCLC that requires further clinical validation.

Prevalence of KRAS mutations in metastatic colorectal cancer: A retrospective observational study from India

BACKGROUND

One of the genetic alterations implicated in tumor progression in colorectal cancers (CRCs) are abnormalities in Kristen Rat Sarcoma (KRAS) gene. Evaluation of KRAS mutation status is an important prognostic factor and has predictive value in deciding first line therapy based on monoclonal antibodies such as Cetuximab and Panitumumab in metastatic CRCs.

MATERIALS AND METHODS

In this retrospective study, we analyzed 7 different somatic mutations in Exon 2 of KRAS gene in 299 unselected incidental CRC patients who visited the hospital for clinical management during the period 2009-2013. Most of the tumors were primarily originating from colon and rectum; nevertheless, there were a few from rectosigmoid, sigmoid, ceacum and anal canal in the study group. Genomic DNA extracted from paraffin embedded tumor tissues was screened for 7 point mutations located in Codons 12 and 13 of KRAS gene, using Scorpions amplified refractory mutation system real time polymerase chain reaction technology. Statistical analysis was performed to assess bivariate relationship between different variables that includes: mutation status, mutation type, tumor location, tumor morphology, age and sex.

RESULTS

Prevalence of mutation in Codons 12 and 13 was 42.8% in the study group. Well-differentiated tumors had significantly more mutation positivity than moderately and poorly differentiated tumors (P = 0.001). 92% of the mutations were from Codon 12 and 8% in Codon 13. Glycine to Arginine was relatively more common in rectosigmoid followed by ceacum, while Glycine to Alanine mutation was relatively more prevalent in sigmoid, followed by rectum and rectosigmoid.

CONCLUSION

The results suggest a prevalence of KRAS mutation at 42.8% in Indian population indicating that this testing is very crucial for targeted therapy management in metastatic CRC in India. Further analysis on mutation status of other homologues such as NRAS and downstream partner, v-raf murine sarcoma viral oncogene homolog B1, would add value to understanding the role of anti-epidermal growth factor receptor therapy in CRC management.

Knee osteoarthritis: a review of management options

Osteoarthritis of the knee is a complex peripheral joint disorder with multiple risk factors. The molecular basis of osteoarthritis has been generally accepted; however, the exact pathogenesis is still not known. Management of patients with osteoarthritis involves a comprehensive history, thorough physical examination and appropriate radiological investigation. The relative slow progress in the disease allows a stepwise algorithmic approach in treatment. Non-surgical treatment involves patient education, lifestyle modification and the use of orthotic devises. These can be achieved in the community. Surgical options include joint sparing procedures such as arthroscopyando osteotomy or joint-replacing procedures. Joint-replacing procedures can be isolated to a single compartment such as patellofemoral arthroplasty or unicompartmental knee replacement or total knee arthroplasty. The key to a successful long-term outcome is optimal patient selection, preoperative counselling and good surgical technique.

Spatial and temporal variations in the accuracy of meteorological drought indices

Meteorological drought indices are commonly calculated using data from weather stations and then interpolated to create a map of moisture conditions. These maps are used to communicate drought information to decision makers and the general public. This study analyzes five of the factors (drought index, interpolation method, seasonality, climate region, and station density) that influence the accuracy of these maps. This study compared the Standardized Precipitation Index (SPI) and Standardized Precipitation Evapotranspiration Index (SPEI) using data from the Cooperative Observer Network (COOP) and United States Historical Climatology Network (USHCN). The accuracy of the drought maps varied significantly over time and space. The most significant factor affecting the accuracy of the meteorological drought maps was seasonality. Errors were higher in regions (e.g., southeastern U.S.), and months (e.g., summer), dominated by convective precipitation. The choice of interpolation method also had an influence. We found that Ordinary Kriging (OK) performed better than Inverse Distance Weighting (IDW) in all cases and therefore it was recommended for interpolating drought indices. Not surprisingly, maps that were created using more stations (COOP) were more accurate. The normalized errors of SPI and SPEI were very similar and so the choice of drought index had little impact on the accuracy of the drought maps.

Waterpipe smoking among health sciences university students: Knowledge, attitude and patterns of use

Introduction

Although waterpipe smoking is common in Gulf counties, its prevalence in Saudi Arabia is uncertain. The purposes of this study were (a) to assess the prevalence of waterpipe smoking among healthcare university students in Saudi Arabia and (b) to determine their attitudes and practices of waterpipe smoking.

Materials and methods

A cross-sectional survey was conducted among university students of three different health sciences colleges, namely medical, dental, and pharmacy, of a public university, through random cluster sampling. The questionnaire was designed to ask specific questions related to smoking in general and to waterpipe smoking specifically. The study was approved by the institutional research & ethics committees.

Results

A total of 535 participants were included in the study. More than one-third of the participants that reported having ever smoked a waterpipe (n = 198, 37%), and the majority of these were current smokers (62.1%, n = 123); dental students were the most common (45.5%, n = 90). Curiosity and pleasure-seeking were the main factors associated with starting waterpipe smoking. About one-sixth (14.9%, n = 80) of the participants failed to identify a single harmful effect, while a vast majority of participants considered waterpipe smoking to be less unhealthy than cigarette smoking.

Conclusion

Waterpipe smoking is very popular among Saudi university students, and knowledge among university students about the dangers of waterpipe smoking is alarmingly low.

Weekly paclitaxel with trastuzumab and pertuzumab in patients with HER2-overexpressing metastatic breast cancer: overall survival and updated progression-free survival results from a phase II study

We previously reported progression-free survival (PFS) results on a phase II trial of weekly paclitaxel, trastuzumab, and pertuzumab in patients with human epidermal growth factor receptor 2(HER2)-positive metastatic breast cancer (MBC) treated in the first- and second-line setting. Here, we report results for overall survival (OS) and updated PFS after an additional year of follow-up. Patients with HER2-positive MBC with 0-1 prior treatment were eligible. Treatment consisted of paclitaxel (80 mg/m(2)) weekly, and trastuzumab (loading dose 8 mg/kg → 6 mg/kg) and pertuzumab (loading dose 840 mg → 420 mg) every 3 weeks, all given intravenously. Primary endpoint was 6-month PFS. Secondary endpoints included median PFS, 6-month and median OS. Evaluable patients received at least one full dose of treatment. From January 2011 to December 2013, 69 patients were enrolled: 51 (74 %) and 18 (26 %) treated in first- and second-line metastatic settings, respectively. As of July 1, 2015, the median follow-up was 33 months (range 3-49 months; 67 patients were evaluable for efficacy). The median OS was 44 months (95 % CI 37.5-NR) overall and 44 months (95 % CI 38.3-NR) and 37.5 months (95 % CI 30.3-NR) for patients with 0 and 1 prior metastatic treatment, respectively; 6-month OS was 98 % (95 % CI 90-1). The 6-month PFS was 86 % (95 % CI 75-93) overall and 89 % (95 % CI 76-95) and 78 % (95 % CI 51-91) for patients with 0 and 1 prior therapy, respectively; and median PFS was 21.4 months (95 % CI 14.1-NR) overall and 25.7 months (95 % CI 14.1-NR) and 16.9 months (95 % CI 8.5-NR) for patients with 0-1 prior treatment, respectively. Treatment was well tolerated. Updated analysis demonstrates that weekly paclitaxel, when added to trastuzumab and pertuzumab, is associated with a favorable OS and PFS and offers an alternative to docetaxel-based therapy. http://www.ClinicalTrials.gov NCT0127604.

Necrotising fasciitis secondary to a colocutaneous fistula

Colocutaneous fistulae secondary to diverticular disease are rare, especially spontaneous fistulae. We report a case of a 74-year-old lady, with no previous history of diverticular disease, presenting with necrotising fasciitis of the anterior abdominal wall in the left iliac fossa, without any other symptoms. Urgent surgery was performed. An initial diagnostic laparoscopy demonstrated a perforated sigmoid diverticulum forming a fistula to the anterior abdominal wall. Following soft tissue debridement, a sigmoid colectomy was performed through a midline laparotomy. Gastrointestinal pathology should be considered as a potential cause of abdominal wall necrotising fasciitis. Our approach of using laparoscopic visualisation to assess for intra-abdominal sources in this context (in the absence of preoperative imaging when imaging could delay treatment) has not been described before. To our knowledge, only two cases of abdominal wall necrotising fasciitis secondary to diverticular disease with a colocutaneous fistula have been reported in the English literature.

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&gt;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 OT2-01-03: A phase 1/2 study of once-daily oral VT-464 in patients with advanced androgen receptor (AR) positive triple negative (TNBC) or estrogen receptor (ER) positive breast cancer (BC)

VT-464, an oral dual lyase-selective CYP17 inhibitor and AR antagonist (wild-type and mutated forms [e.g., F876L and T877A]), is in multiple Phase (Ph) 2 studies as treatment for men with castration-resistant prostate cancer (CRPC). VT-464 inhibits the growth of multiple BC cell lines in vitro including MCF7 (ER(+)/AR low), tamoxifen-resistant MCF7, and MDA-MB-453 (ER(-)/AR(+)) in a dose-dependent manner and with greater potency/efficacy than enzalutamide (submitted, Ellison et al., 2015). A subset of TNBC and most ER(+) BC express AR, making them potential targets for VT-464 since it directly inhibits both androgen/estrogen synthesis and AR transcriptional activity.

Objectives: The primary objective of Ph 1, now enrolling, is to establish the once-daily dose of VT-464 in women. Secondary objectives include safety, PK and efficacy endpoints, including determination of clinical benefit rate (CBR) which is the primary objective of Ph 2. Exploratory objectives include the determination of the extent of AR expression and signaling in breast tissue and to evaluate the relationship of expression with VT-464 effects on circulating tumor biomarkers, circulating hormones and clinical outcomes.

Study Design: This study is an open-label, single arm, Ph 1/2 study of VT-464 in women with AR(+) TNBC or ER(+)/HER2 normal unresectable locally advanced or metastatic BC. Ph 1 will follow a modified 3+3 Fibonacci design with cohort expansion to 6 patients following a single DLT in the first 28-days of treatment. Approximately 2-3 dose-levels will be explored in Ph 1. Ph 1 start dose will be the MTD for men with CRPC. AR(+) TNBC and ER(+)/HER2 BC cohorts will be expanded in Ph 2 using the MTD from Ph 1. Ph 2 will follow a Simon's two-stage design with pre-determined futility parameters. Eligible patients will have ER≥1% BC or AR≥1% (as determined by central IHC testing using the Dako antibody) TNBC. ER(+) patients must be postmenopausal and must have received at least 1 prior line of endocrine therapy. Additional eligibility criteria include: ≥ 18 years of age, ECOG PS ≤ 1, unresectable locally advanced or metastatic BC, available representative tumor specimen to enable correlative science.

Treatment Plan: Eligible patients will receive VT-464 once-nightly with dinner in a continuous dosing schedule. Adverse events and concomitant medications will be collected from the time of signing of informed consent until 30 days after end of study visit (EOS). Safety labs will be monitored monthly through EOS. Dense PK will be collected after the first dose of study drug in Ph 1 and single morning samples collected approximately every two cycles thereafter in Ph 1 and Ph 2 until EOS. Blood samples for steroids, circulating tumor DNA and circulating tumor cells will be collected through Cycle 2 and then at EOS. Tumor biopsy will be collected at baseline and at disease progression. Radiographic response will be assessed every 8 weeks and EOS.

Patient Accrual: Accrual is ongoing with 12-18 patients expected to be enrolled in Ph 1.

Citation Format: Gucalp A, Hudis C, Norton L, Patil S, Kurman MR, Eisner JR, Moore WR, Traina TA. A phase 1/2 study of once-daily oral VT-464 in patients with advanced androgen receptor (AR) positive triple negative (TNBC) or estrogen receptor (ER) positive breast cancer (BC). [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 OT2-01-03.

Abstract P6-07-01: Multigene profiling to identify clinically relevant actionable mutations in breast cancer: An Indian study

Background: Numerous chemotherapeutic agents are available against breast cancer (BC), but a vast majority of patients diagnosed with this disease still develop treatment resistance and eventually succumb to disease. It remains an unmet need to identify specific molecular defects against which targeted therapy are available for improving clinical outcomes in BC. Our study aims to identify frequent hotspot mutations in BCs and determine their clinical impact.

Methods: 200 women with BC(early diagnosed and/or metastatic) aged 26-75 yrs (median age 50.5yrs) diagnosed at HCG from April 2013-15 were consented to be profiled by targeted deep sequencing for hotspot mutations in 48 cancer-related genes using Illumina's TSCAP panel and MiSeq technology in an IRB-approved prospective study in a CLIA compliant laboratory. All the cases had pathology review for stage, histological type, hormonal status and Ki67. The average coverage across 220 hot spots was greater than 1000X. Data was processed using Strand Avadis NGS™. Mutations identified in the tumor were assessed for 'actionability' i.e. response to therapy and impact on prognosis. Results: Somatic variants were detected in 75% of cases with direct impact on therapy or prognosis. Genetic aberrations were identified in PI3K/AKT/ mTOR signalling pathway in substantial fraction (27%) of breast cancer cases, out of which 17% had PIK3CA activating mutations,13 and 5 cases had PTEN and AKT deletions or truncating mutations respectively. Aberration in this pathway was more prevalent in HR+ve (53%) and HER2-ve including TNBC (61%) than in HR+/HER2+ve tumors (10.6%) of IDC histology. However, no correlation was found with stage and Ki67 index of the tumor. Notably 80% of BC cases presented with liver metastasis at the time of diagnosis were detected with PIK3CA mutation indicating its role as a surrogate marker of organ specific metastasis. PIK3CA was found to be co mutated with p53 in 16 cases (9%) of which 4 cases showed npCR post NACT. Also disruptive and non-disruptive mutations in TP53 alone were found in 25% of BC, varying widely among different histologies. A follow up of few cases showed shorter PFS and poor outcome in resected BC treated with NACT indicating its robust prognostic value in NACT setting. Furthermore, two patients were detected with cKIT mutations indicating sensitivity to imatinib and therefore enrolled on a clinical trial. The other variants were found in RB1(n=8),Her2 (n=2),FGFR amplification(n=1), KRAS(n=2),NRAS(n=3)CDH1(n=1),FBXW7(n=2) and EGFR(n=1).All these variants detected indicated resistance to conventional therapy and suggested sensitivity to available targeted therapy, either approved or in clinical trials. The response and outcome are being monitored in about 20 (10%) patients who have been enrolled in clinical trials and receiving mutation specific targeted therapy. Conclusions: This study confirms the utility of multigene profiling in early diagnosed and advanced BC patients, to stratify them on their molecular profile who could potentially benefit from targeted therapy. Prospective studies and randomized clinical trials are ongoing to confirm the independent prognostic and therapeutic value of the mutations in a larger cohort of Indian population.

Citation Format: Ghosh M, Sheela ML, Choudhury S, Bahadur U, Patil S, Satheesh CT, Murugan K, Nayak R, Sridhar PS, Rao N, Mahesh B, Shashidhara HP, Krishnamoorthy N, Gupta V, Sankaran S, Subramanian K, Ajaikumar BS. Multigene profiling to identify clinically relevant actionable mutations in breast cancer: An Indian study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-07-01.

Abstract P1-14-17: Pathologic complete response rate with doxorubicin and cyclophosphamide followed by weekly paclitaxel with trastuzumab and pertuzumab in patients with HER2-positive early stage breast cancer: A single institution experience

Background:

Trastuzumab and pertuzumab (HP) with standard chemotherapy is approved for use in the neoadjuvant setting. We performed a retrospective analysis of patients (pts) treated with dose-dense doxorubicin and cyclophosphamide (AC) → paclitaxel, trastuzumab, pertuzumab (THP) in the neoadjuvant setting. Here we report the pathologic complete response (pCR) rate.

Methods:

We abstracted medical records of patients who were treated with pertuzumab-based therapy in the neoadjuvant setting from September 1, 2013 to March 1, 2015. Charts were analyzed for pt demographics, stage of breast cancer, pathology reports, surgical data, and information on systemic therapy.

Results:

Charts from 66 pts were reviewed; 60 pts were evaluable for pCR defined as absence of invasive disease in the breast, and 6 were not (3-no anthracycline, 1-incomplete chart, 1-no surgery yet, 1-metastatic). Median age was 47 years (range 28-68 years). Of 60 pts, 52 (86%) had operable breast cancer (T1-3, N0-1, M0) of which 7 had clinical stage I disease (T1N0)]; 7 (12%) had locally advanced disease (T2-3, N2-3, M0 or T4a-c, any N, M0), and 1 (2%) had inflammatory breast cancer (T4d, any N, M0). 49 (82%) and 11 (18%) had hormone receptor (HR)-positive and negative diseases, respectively. All patients had HER2-positive breast cancer defined as immunohistochemistry (IHC) 3+ and/or fluorescent in-situ hybridization (FISH) of &gt; 2.0. 30 pts (50%) underwent mastectomy and lumpectomy, respectively. Out of 60 evaluable pts, 41 (68%) had pCR; 32/49 (65%) with HR-positive and 9/11 (82%) with HR-negative diseases had pCR, respectively. Overall 58/60 (97%) pts completed neoadjuvant therapy; 2 did not (1 developed Steven Johnson Syndrome after one cycle of AC and 1 developed pneumonitis after third weekly dose of T with HP).

Conclusions:

At our single center experience the pCR rate of dose dense AC→THP is high at 68 %. These data are similar to results seen in the TRYPHAENA study, and we await the results from the BERENICE trial evaluating pCR as a secondary endpoint.

Patient Demographics Age, years &lt;4525 (42%)45-5419 (32%)&gt;5516 (26%) ECOG Performace Status 031 (52%)129 (48%) Hormone receptor (HR) status HR+ Her2+49 (82%)HR- Her2+11 (18%) Status of Her-2 Positivity IHC positive52 (86%)FISH positive8 (14%) Median tumor size2.6cm (range: 1-8.4cm) Stage Operable (T1-2, N0-1, M0)52 (86%)Operable Stage I7 (12%)Operable Stage II/III45 (74%)Locally advanced (T2-3, N2-3, M0 or T4a-c, any N, M0))7 (12%)Inflammatory (T4d, any N, M0)1 (2%) Type of surgery Lumpectomy30 (50%)Mastectomy30 (50%)

Citation Format: Singh JC, Sugarman S, Jones L, Boafo C, Patil S, Schweber S, Yu A, Argolo D, Modi S, Iyengar N, Smyth L, Norton L, Baselga J, Hudis C, Dang C. Pathologic complete response rate with doxorubicin and cyclophosphamide followed by weekly paclitaxel with trastuzumab and pertuzumab in patients with HER2-positive early stage breast cancer: A single institution experience. [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 P1-14-17.

Abstract P4-13-20: Activity of HP-based therapies as third and later lines for the treatment of HER2-positive metastatic breast cancer: A retrospective study from a single institution

Background: Dual anti-HER2 blockade with trastuzumab and pertuzumab (HP) plus chemotherapy is an effective therapy (Rx) in the 1st-line setting for HER2-positive metastatic breast cancer (MBC). Our single arm phase II study included patients (pts) treated with HP plus paclitaxel in the 2nd-line setting with progression-free survival (PFS) benefit. Recently, we reported results from a retrospective study of pts treated at our institution, suggesting a longer PFS for those who received HP-based Rxs when compared to any other anti-HER2 based Rxs in the 2nd-line setting. To further assess the activity of this combination in later Rx lines, we conducted a retrospective analysis of pts with HER2-positive MBC who had progressive disease after 2nd-line and were treated with HP-based Rxs in the 3rd and later lines at MSKCC. Historically, the median (med) PFS in this setting with trastuzumab-based Rx is about 3-4 months.

Methods: Pts diagnosed with HER2-positive MBC and treated with HP-based Rxs at MSKCC between 1-1-2011 and 03-30-2015 and who progressed on 2nd-line Rx were identified through an institutional database. Primary endpoint was PFS in 3rd and later treatment lines.

Results: 70 pts who received any HP-based Rx in the 3rd or later lines of treatment were eligible. The med number of prior anti-HER2 Rx was 3. The baseline characteristics and Rxs are summarized in Table 1. The med PFS for the entire cohort was 5.7 months (95% CI, 4.8-6.5).

Conclusions: In this retrospective analysis involving heavly pretreated patients, HP-based Rx appears to be an active regimen and compares favorably to historical data. This supports the NCCN endorsement of HP-based Rx in later lines if HP has not been delivered previously.

Baseline Characteristics and treatments (n=70)Characteristic(n)(%)Age  Median56 Range27-83 Gender  Female70100.0Male00.0Race  Black1014.3White5477.1Other68.6Ethnicity  Non Hispanic6694.3Hispanic45.7ER/PR status  ER and PR negative2738.6ER and/or PR positive4361.4Type of disease  Non visceral1622.9Visceral5477.1Visceral CNS2130.0Anti-HER2 in early stage  Yes2941.4No4158.6Line of therapy  3rd line1927.14th line1521.45th line912.96th line912.97th line811.48th line and beyond1014.3HP-based regimens  Chemotherapy + HP5477.1Endocrine therapy + HP57.1HP alone912.9Other22.9

Citation Format: Argolo D, Friedman M, Smyth L, Iyengar N, Singh J, Patil S, Norton L, Baselga J, Hudis C, Dang C. Activity of HP-based therapies as third and later lines for the treatment of HER2-positive metastatic breast cancer: A retrospective study from a single institution. [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 P4-13-20.

Abstract P6-06-06: Comprehensive analysis of BRCA (BRCAm) and other germline mutations (GRm) with a clinicopathological association in breast cancer: An Indian study

Background: BRCAm and other GRm testing using next generation sequencing (NGS) in early diagnosed and/or metastatic breast cancer (BC) helps in the identification of both unambiguously defined deleterious mutations and sequence variants of unknown clinical significance (VUS). The early detection of these mutations in the proband and the family members help in risk stratification and instituting effective monitoring, surveillance and disease management strategies.

Methods: Out of total 200 patients diagnosed with BC (April 2013-15) 77 unrelated individuals were consented to be profiled by NGS on MiSeq platform using TruSight Cancer panel (consisting of 94 genes including 13 genes highly associated with risk of inherited breast and/or ovarian cancer) in an IRB-approved prospective study in a CLIA compliant laboratory. Paired end sequencing was done with an average coverage of &gt; 450X. Data was processed using STRAND software and interpreted using "Strand Omics" platform. The paired tumor samples were analysed for pathological stage, histological type and hormonal status.

Results: GRm were detected in 61 cases (79%). Among all mutations detected, BRCA1/2 were found in 51% (31% in BRCA1, 20% in BRCA2) of cases. BRCA1 was found to be co-mutated with BRCA2 in 2 cases. Out of 37 deleterious mutations in BRCA1/2 genes only 10 were reported to be pathogenic (6 in BRCA1 and 4 in BRCA2) and rest were VUS. Mutation frequencies were higher among high grade IDC with HER2-ve tumors including TNBC (53%, p&lt;0.05) with an early onset of the disease. TNBC with BRCAm were found to have no/incomplete pCR on conventional TAC regimen , subsequently started with platinum therapy and the outcome being monitored. Interestingly, 4 BRCA1 mutations including 3 non-sense and 1 frameshift mutation were found in two unrelated individuals suggesting them to be founder mutations in Indian population. The other GRm frequency (alone/ co-mutated with BRCA) was also found to be significantly high (49%) and include BRIP1, CHEK2, ERCC2, CDH1, SDHB, APC, MSH6, TP53, PALB2 and RAD51C. Stratification based on age of diagnosis(dx) showed a detection rate significantly higher in the age group of 25-50 yrs (74%) as compared to the 50-75 yrs (26%). Also a strong association of GRm status with the family history(Hx) of BC in 1st or 2nd degree relatives was indicated.

Table 1: Correlation of GRm with Dx and HxGenen%Age at dx(yrs)Family Hx (Yes=Y, No=N,Unknown=UK)BRCA1193125-50 (n=23) 50-75(n=8)Y(n=13) N(n=3) UK(n=3)BRCA2122025-50(n=21) 50-75(n=9)Y(n=8) N(n=2) UK(n=2)PALB211.7&gt;50YCHEK258.825-50 (n=4) 50-75(n=1)YATM610.525-50 (n=4) 50-75(n=2)Y(n=5) N(n=1)RAD5111.7&lt;50Y

Conclusions: Our study in a small cohort clearly highlighted the significance of germline testing and classifying the variant in larger cohort of BC patients with a strong family Hx of cancer particularly in BRCA1/2 positive families , and in women &lt;50yrs for early detection and risk assessment. The study also indicates BRCAm to be an important contributor to the etiology of high grade HER2-/ TNBC in Indian patients. Expanded testing of this subtype is warranted to impact management of the disease with PARP inhibitors and/or platinum therapy.

Citation Format: Ghosh M, ML S, Upasana M, Chodhury S, Mannan AU, Southekal S, Manjima C, Patil S, Murugan K, Mahesh B, Nayak R, Sridhar PSS, Rao N, Krishnamoorthy N, Gupta V, Satheesh CT, Subramanian K, Ajaikumar BS. Comprehensive analysis of BRCA (BRCAm) and other germline mutations (GRm) with a clinicopathological association in breast cancer: An Indian study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-06-06.

Abstract OT1-01-05: Phase 1b/2 study of intratumoral Ad-RTS-hIL-12 + veledimex in patients with chemotherapy-responsive locally advanced or metastatic breast cancer

Background: Immune-based strategies involving T-cell activation have recently shown significant activity in multiple tumor types. The presence of immune elements in breast cancers has prognostic and predictive impact. Thus, strategies that optimize the interplay between a breast cancer and the effected individual's immune system may be therapeutic. Interleukin-12 (IL-12), a pro-inflammatory cytokine, reverses immune escape mechanisms induced by myeloid derived suppressor and dendritic cells which, in turn, improves the function of activated CD8+ T cells and promotes tumor stroma collapse. Because tumor neoantigens may be generated in response to chemotherapy, IL12-mediated immune modulation may be optimal in patients with chemotherapy-sensitive metastatic breast cancer. Ad-RTS-hIL-12 (Ad) is a novel gene therapy candidate expressing IL-12 under the control of an orally-administered activator ligand, veledimex (V) through the proprietary RheoSwitch Therapeutic System® (RTS).

Trial Design: Open-label, phase 1b/2, single-arm, single-center study of Ad+V in women with stable or responsive disease after ≥ 12-weeks of 1st or 2nd-line chemotherapy. Eligible patients will be placed on chemotherapy-holiday and enter the immunotherapy phase, consisting of a single cycle of Ad administered intratumorally (Day 1), along with V (80 mg QDx7). HER2-directed antibody therapy may be continued during the immunotherapy phase for women with HER2- disease.

Key Eligibility Criteria: Women ≥18 years with histologically-confirmed locally advanced or metastatic breast cancer of any subtype who have achieved a partial response (PR) or stable disease (SD) to 1st or 2nd-line chemotherapy are eligible. Exclusion criteria include use of immunosuppressive drugs, compromised immune function, autoimmune disorder, or brain metastases.

Specific Aims: To evaluate the safety and tolerability of Ad+V immunotherapy in eligible women. Secondary endpoints include 12 week overall response rate, 12 week disease control rate and the impact of treatment on exploratory immune biomarkers.

Statistical Methods: Safety and efficacy will be evaluated separately for HER2-/HER2+ patients. Tumor response will be evaluated by RECIST v1.1 at 6 and 12 weeks. To ensure safety, stopping rules defined by grade 3/4 adverse events and12-week progression rate were adopted.

Target Accrual: Up to 40 patients, including up to 8 patients (20%) with HER2+ disease.

Summary: Ad+V is a novel gene therapy which controls local expression of IL-12 and may induce tumor stroma collapse and stimulation of an anti-cancer T cell immune response. The ability to regulate the production of IL-12 by modulating V dosing may result in an improved therapeutic index in combination with standard of care. The data from this study will directly inform future studies.

Study Contact (Clinical Trials.gov: NCT02423902).

Citation Format: McArthur HL, Page D, Proverbs-Singh T, Solomon S, Hudis C, Norton L, Patil S, Barrett JA, Lebel F. Phase 1b/2 study of intratumoral Ad-RTS-hIL-12 + veledimex in patients with chemotherapy-responsive locally advanced or metastatic breast cancer. [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 OT1-01-05.

Abstract P4-14-24: Optimization of intermittent high dose lapatinib administration with or without capecitabine: A rational approach to drug dosing and scheduling using Norton-Simon modeling

Background: Systemic treatment of central nervous system (CNS) metastases remains a challenge partially due to poor drug penetration. Lapatinib and capecitabine are drugs with modest efficacy in treatment of brain metastases from HER2-positive (+) breast cancer (BC) and were shown to cross the blood-tumor barrier in clinical craniotomy specimens (Lin N et al., CCR 2009, Morikawa A et al., Neuro Oncol 2015). However, intratumoral drug concentrations observed were sub-optimal and heterogeneous. Administration of shorter-duration, high dose tyrosine kinase inhibitor is proposed as a way to improve efficacy and tolerability based on Norton-Simon modeling and drug exposure in the CNS (Traina T et al., JCO 2008, Grommes C et al., Neuro Oncol 2011, Chien AJ et al., J Clin Oncol 2014) . In this study, we examined optimization of high dose lapatinib administration with or without capecitabine to inform the design of a phase I trial for BC patients with HER2+ CNS metastases.

Methods: Mice bearing BT-474 BC xenograft tumors were treated with various lapatinib doses and schedules. A standard continuous daily dose (100mg/kg) was compared to various intermittent dosing schedules (at 100mg/kg, 400mg/kg, and 800mg/kg). In addition, high dose lapatinib (800mg/kg) was administered with capecitabine either concurrently or in tandem. Xenografts were treated when tumors reached 100mm3. Tumor volumes were evaluated for antitumor efficacy, and mice weights were measured for toxicity. Significance testing for between-group comparisons was conducted using a mixed effect model for repeated measures.

Results: Intermittent schedules of lapatinib at 100mg/kg given as 3 days on/11 days off (3/11), 5 days on/9 days off (5/9), and 7 days on/7days off (7/7) had a similar efficacy in tumor control: percent change in tumor volume of 225% (7/7), 222% (5/9), and 223% (3/11) (NS). Therefore, the 3 days on (with 4 days off or 11 days off ) schedule was subsequently chosen to evaluate for tolerability and antitumor efficacy of higher lapatinib dose. The 3 days on/4 days off (3/4) group at 800mg/kg demonstrated the highest tumor reduction (-69%) compared to the daily continuous dosing group (-18%) (p=0.04), but a trend toward higher toxicity was observed (p=0.12). Evaluation of concurrent vs. tandem administration of capecitabine with lapatinib at 800mg/kg given in 3 days on/11 days off was conducted. The concurrent treatment was discontinued early due to high toxicity. However, tandem administration of capecitabine with high dose lapatinib was tolerable without a significant difference in weight changes (p=0.62).

Conclusions: The intermittent schedule allows delivery of high dose lapatinib, which has better anti-tumor activity than standard continuous dosing. If given intermittently, high dose lapatinib is tolerable, even with capecitabine if given in tandem/sequence. Based on the result of these experiments, a phase I trial of high dose lapatinib using 3 days on/11 days off schedule in tandem with capecitabine is currently proposed for treatment of HER2-positive BC patient with CNS metastases.

Citation Format: Morikawa A, De Stanchina E, Patil S, Chandarlapaty S, Li BT, Norton L, Seidman AD. Optimization of intermittent high dose lapatinib administration with or without capecitabine: A rational approach to drug dosing and scheduling using Norton-Simon modeling. [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 P4-14-24.