Abstract P5-16-02: Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant

Introduction: The appearance after breast surgery has become an important aspect of survivorship. The post lumpectomy/post radiation hollow surgical defect negatively impacts cosmesis and patient satisfaction. Oncoplastic procedures will mobilize surrounding tissues into the lumpectomy cavity but adds no volume to the breast. Use of a bioabsorbable 3-dimensional tissue implant (used for targeting radiation) has the additional benefit of adding volume to the breast and enhances the overall cosmetic appearance. Our experience over 3 years provides serial mammograms from which we may objectively categorize cosmetic contour. We report on our 2 and 3 year serial images of our treated patients compared with baseline.

Methods: Between May 2014 and June 2018, during lumpectomy for breast cancer we implanted a 3-D tissue implant marker in 170 patients, often combined with oncoplastic reconstruction and followed by radiation treatment. For long term follow-up we had 37 patients with serial mammograms at 2 or 3 years to assess cosmesis. All patients had interviews, physical exams, and serial mammograms to evaluate their cosmetic appearance. Both physician and patient graded their appearance. We also objectively measured and compared the pre-treatment mammogram and the 2-year and 3-year, post-treatment mammogram for symmetry and size using each breast as its own control. Using the post-treatment mammograms, we compared the relative anterior-posterior (depth) measurement of the quadrant bearing the implant as well as the non-cancer quadrant to the similar locations of the pre-treatment mammogram. Both mammogram positioning and radiation effects would balance. We compared the relative change from baseline in the non-cancer portion of the breast to the change from baseline in the cancer portion of the breast as a percent difference from baseline.

Results: Patients were treated with lumpectomy, oncoplastic reconstruction, and placement of a 3-D tissue implant. Three implants were removed due to positive margins. No implants were removed for any other reason. There have been no local recurrences. Overall, radiation oncologists felt the 3-D implant was useful for treatment planning in 85% of patients. Of the 37 consecutive patients who have completed an average of 27.8 months of follow-up, cosmesis was rated as excellent/good by clinicians (96%) and patients (94%). Mammograms taken at 2-3 years were compared with initial images. Whole-breast radiation effect varied among patients. Some had significant shrinkage while others had none. These changes were equal in the non-cancer post-radiation quadrants (86.2% vs 87%) demonstrating maintenance of normal breast contour. Our use of the 3-D implant and oncoplastic tissue advancement maintained the pre-operative contour of the breast after lumpectomy with radiation.

Conclusions: Breast cancer surgery and radiation is often complicated by poor cosmesis with retraction and volume loss. Using a combination of oncoplastic surgery combined with a 3-D tissue implant, we found the forward projection and contour of the breast at the lumpectomy site was preserved and patient satisfaction was good to excellent. Further investigation of the long-term cosmetic effects of breast cancer surgery should be encouraged.

Citation Format: Kaufman CS, Hall W, Behrndt VS, Wolgamot GM, Zacharias K, Rogers A, Smith A, Hill LM, Schnell N. Enhance post-lumpectomy breast contour using oncoplastic surgery (OPS) plus a bioabsorbable 3-D tissue implant [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-02.

Early Onset Neonatal E.Coli Sepsis

This was a retrospective case-control study over 14 years comparing characteristics of neonates who developed E.coli bacteraemia with matched infant controls whose mothers were colonised with E.coli on high vaginal swab but who did not develop bacteraemia. Data was obtained from maternal and neonatal charts, the laboratory data-base was analysed to identify possible risk factors for E.coli bacteraemia. 21 cases and 38 controls were identified. The data showed no difference in gender, maternal age, white cell count, or cord pH. Significant differences were found in gestation (33 vs. 39.5wks p<0.01), weight (1.64 vs. 3.08 kg p<0.001) and duration of preterm, pre-labour rupture of membranes (pPROM) (6 vs. 2.9 days p=0.04) between cases and controls. Risk factors for E.coli bacte-raemia were identified, most notably duration of pPROM. A re-evaluation of antimicrobial therapy in neonates with a maternal pPROM >5 days is advised.

The Effect of Adjunctive Fresh Frozen Plasma Administration on Coagulation Parameters and Survival in a Canine Model of Antivenom-treated Brown Snake Envenoming

This study aimed to assess the effects of dugite envenoming on blood coagulation and platelet count in a canine model, and the efficacy of fresh frozen plasma (FFP) in reversing the clotting disorder after both adequate and inadequate venom neutralization. Following initial dosing and administration studies, an intravenous venom dose of 1μg/kg was administered to eleven dogs. This was followed 30 minutes later by antivenom in either adequate or inadequate doses. A further 30 minutes later, the animals were given either two units of their own FFP or saline. Fibrinogen, aPTT and platelet levels were monitored for eight hours.

Of the six study dogs given antivenom plus FFP, two died at around 60 to 90 minutes post envenoming, at the end of the FFP infusions, and all but one of the survivors had persistent afibrinogenaemia. Of the five study dogs given antivenom and no FFP, all but one had return of detectable fibrinogen at eight hours after envenoming. The platelet count fell in all animals with recovery independent of antivenom dose, administration of FFP, or regeneration of fibrinogen. Post mortem examinations of dogs that died during dosage and administration studies showed massive intracardiac clots.

We conclude that early death from Brown Snake envenoming may be due to massive intravascular clotting. FFP administration was associated with persistent afibrinogenaemia regardless of antivenom dose. In the absence of any evidence for its efficacy, this study suggests that the role of FFP after Brown Snake envenoming should be reconsidered.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC.

METHODS

This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred.

RESULTS

There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63).

CONCLUSIONS

The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

Continuous monitoring and feedback of quality of recovery indicators for anaesthetists: a qualitative investigation of reported effects on professional behaviour

Background

Research suggests that providing clinicians with feedback on their performance can result in professional behaviour change and improved clinical outcomes. Departments would benefit from understanding which characteristics of feedback support effective quality monitoring, professional behaviour change and service improvement. This study aimed to report the experience of anaesthetists participating in a long-term initiative to provide comprehensive personalized feedback to consultants on patient-reported quality of recovery indicators in a large London teaching hospital.

Methods

Semi-structured interviews were conducted with 13 consultant anaesthetists, six surgical nursing leads, the theatre manager and the clinical coordinator for recovery. Transcripts were qualitatively analysed for themes linked to the perceived value of the initiative, its acceptability and its effects upon professional practice.

Results

Analysis of qualitative data from participant interviews suggested that effective quality indicators must address areas that are within the control of the anaesthetist. Graphical data presentation, both longitudinal (personal variation over time) and comparative (peer-group distributions), was found to be preferable to summary statistics and provided useful and complementary perspectives for improvement. Developing trust in the reliability and credibility of the data through co-development of data reports with clinical input into areas such as case-mix adjustment was important for engagement. Making feedback specifically relevant to the recipient supported professional learning within a supportive and open collaborative environment.

Conclusions

This study investigated the requirements for effective feedback on quality of anaesthetic care for anaesthetists, highlighting the mechanisms by which feedback may translate into improvements in practice at the individual and peer-group level.

KIR2DL4-HLAG interaction at human NK cell-oligodendrocyte interfaces regulates IFN-γ-mediated effects

Interactions between germline-encoded natural killer (NK) cell receptors and their respective ligands on tumorigenic or virus-infected cells determine NK cell cytotoxic activity and/or cytokine secretion. NK cell cytokine responses can be augmented in and can potentially contribute to multiple sclerosis (MS), an inflammatory disease of the central nervous system focused upon the oligodendrocytes (OLs). To investigate mechanisms by which NK cells may contribute to MS pathogenesis, we developed an in vitro human model of OL-NK cell interaction. We found that activated, but not resting human NK cells form conjugates with, and mediate cytotoxicity against, human oligodendrocytes. NK cells, when in conjugate with OLs, rapidly synthesize and polarize IFN-γ toward the OLs. IFN-γ  is capable of reducing myelin oligodendrocyte and myelin associated glycoproteins (MOG and MAG) content. This activity is independent of MHC class-I mediated inhibition via KIR2DL1, but dependent upon the interaction between NK cell-expressed KIR2DL4 and its oligodendrocyte-expressed ligand, HLA-G. NK cells from patients with MS express higher levels of IFN-γ following conjugation to OLs, more actively promote in vitro reduction of MOG and MAG and have higher frequencies of the KIR2DL4 positive population. These data collectively suggest a mechanism by which NK cells can promote pathogenic effects upon OLs.

"We're really not ready for this": A qualitative exploration of community pharmacy personnel's perspectives on the pharmaceutical care of older people with sensory impairment

Background

In most developed countries there is an increasing ageing population living in the community with long-term conditions and sensory impairment (sight; hearing; dual impairment). Community pharmacy personnel are key providers of pharmaceutical care to this patient population.

Objective

This study explored community pharmacy personnel's experiences with providing pharmaceutical care for older people with sensory impairment.

Methods

Semi-structured telephone interviews were conducted with community pharmacy personnel across Scotland between 2015 and 2016.

Results

Thirty interviews were completed with community pharmacists (n = 17) and other pharmacy personnel (n = 13). Two overarching themes emerged: safety and communication. Interviewees reported patients' reluctance to disclose their impairment “patients are very good at hiding it” and had considerable safety concerns “it's a fear that they're going to take too much … accidentally taking the same medicine twice”. Difficulties in communication were cited “no matter what you do or how you label things, leaflets and telling people, things can go wrong”. Additionally, interviewees identified training needs to increase their disability awareness and to identify strategies to provide safe and reliable pharmaceutical care to this vulnerable group “We don't specifically have anything in place to deal with anyone with impairments of that kind”.

Conclusions

This is the first in-depth exploration of providing pharmaceutical care to older people with sensory impairment from the perspective of community pharmacy personnel. Strategies are needed to encourage older people to disclose their sensory impairment. Education and training are also needed to optimise the provision of pharmaceutical care to this vulnerable population.

Response rate to a single dose of vinblastine administered to dogs with treatment-naive multicentric lymphoma

Vincristine is included in vincristine, cyclophosphamide, doxorubicin and prednisone (CHOP) chemotherapy protocols, which are the gold-standard treatment for high-grade canine lymphoma. Vincristine can result in relatively high rates of gastrointestinal toxicity, whereas vinblastine is generally well tolerated and thus may represent an under-utilized and minimally toxic alternative to vincristine. Our objective was to determine the response rate and toxicity associated with a single dose of vinblastine administered to dogs with treatment-naïve, intermediate to large-cell, multicentric lymphoma. Twenty client-owned dogs were enrolled with signed owner consent. A Simon's minimax, phase II, two-stage trial was performed to test the efficacy of vinblastine administered at 2 mg/m² IV followed by a pilot trial of vinblastine at 2.5 mg/m² . No dogs were administered concurrent steroids or other chemotherapy. One out of 14 dogs receiving vinblastine at 2 mg/m² demonstrated a partial response. Three out of five dogs demonstrated a partial response to vinblastine at 2.5 mg/m² . Gastrointestinal toxicity was infrequent and low grade for both groups. The majority of dogs (80%) in the 2.5 mg/m² dosing group developed neutropenia 1-week post administration. Vinblastine was well tolerated but minimally efficacious at a dose of 2 mg/m² IV in dogs with treatment-naive, multicentric lymphoma. Because of poor response rates, treatment at this dose is not recommended. A small subset of dogs administered 2.5 mg/m² had significantly improved response rates (P = 0.04), suggesting that higher doses may have improved efficacy, although further research is indicated to confirm these preliminary findings.

Staff Attitudes towards Patient Safety Culture and Working Conditions in an Irish Tertiary Neonatal Unit

Introduction There is little published research evaluating attitudes towards patient safety culture and working conditions in neonatal units. This study aimed to explore this within a Level III Irish neonatal unit setting. Methods This was a quantitative, cross-sectional study performed in the Rotunda Hospital, Dublin. A 30-item safety attitudes questionnaire (SAQ) was utilized to analyze staff perceptions in areas including job satisfaction, working conditions and stress recognition. Results The ‘Stress Recognition’ domain received the highest score (75.3) followed by ‘Job Satisfaction’ domain with a mean score of 74.4. The lowest mean scale score in the neonatal unit was for ‘Perceptions of Management’, with a mean score of 50.7. Collaboration and Communication scores were high across all disciplines. Conclusion This SAQ has highlighted a number of important areas for quality improvement and staff satisfaction in our neonatal unit.

Sources and survival of Listeria monocytogenes on fresh, leafy produce

Listeria monocytogenes is an intracellular human pathogen which enters the body through contaminated food stuffs and is known to contaminate fresh leafy produce such as spinach, lettuce and rocket. Routinely, fresh leafy produce is grown and processed on a large scale before reaching the consumer through various products such as sandwiches and prepared salads. From farm to fork, the fresh leafy produce supply chain (FLPSC) is complex and contains a diverse range of environments where L. monocytogenes is sporadically detected during routine sampling of produce and processing areas. This review describes sources of the bacteria in the FLPSC and outlines the physiological and molecular mechanisms behind its survival in the different environments associated with growing and processing fresh produce. Finally, current methods of source tracking the bacteria in the context of the food supply chain are discussed with emphasis on how these methods can provide additional, valuable information on the risk that L. monocytogenes isolates pose to the consumer.

Investigation of the influence of a large steel plate on the magnetic field distribution of a magnetic proximity detection system

A magnetic proximity detection system is mounted on a mobile mining machine to prevent underground workers from being pinned or struck by machine motion. The system generates magnetic fields around the machine to determine safe working distances. The miner-worn component measures the magnetic field in order to approximate location. Large masses of steel, such as those from mining equipment, can alter the magnetic field distribution. This affects the locational accuracy of the system, thus adversely impacting worker safety. To examine this problem, U.S. National Institute for Occupational Safety and Health researchers developed a method and test system to study the influence of a steel mass on the magnetic field distribution. The results show that a steel plate can strengthen the magnetic field perpendicular to the generator by up to 40 percent. Furthermore, they show that the degree of the influence on the field distribution is a function of distance. The results from this study can be used to further develop and improve the performance and reliability of electromagnetic proximity detection systems used in underground mining applications.

ACTIVE - a randomised feasibility trial study protocol of a behavioural intervention to reduce fatigue in women undergoing radiotherapy for early breast cancer: study protocol

Background

Fatigue is rated as the most distressing side effect of radiotherapy treatment for curable breast cancer. About four in ten women treated experience fatigue, which can last for years after treatment. The impact of this debilitating tiredness is loss of independence and impaired physical and mental function. Our study will take a behavioural intervention with demonstrated effect in treating fatigue in a mixed group of chemotherapy patients and adapt it for women undergoing radiotherapy for early breast cancer. The purpose of this trial is to evaluate the feasibility of delivering the intervention in the radiotherapy pathway for patients at a high risk of fatigue and to explore participants' experiences of the trial and intervention.

Methods

A pragmatic single-site non-blinded feasibility trial of a behavioural intervention. Main inclusion criteria are prescription of the UK standard 40 Gy in 15 fractions over 3 weeks of radiotherapy (± tumour bed boost) for early (stage 0-IIIa) breast cancer. The total projected sample size after attrition is 70. A previously developed fatigue risk score tool will be used to predict individual's likelihood of experiencing fatigue. Thirty women predicted to be at a high risk of experiencing significant fatigue will be allocated in the ratio 2:1 to the behavioural intervention or education trial arms, respectively. These feasibility trial participants will be assessed at baseline, after 10 and 15 fractions of radiotherapy and 10 days, 3 weeks and 6 months after radiotherapy. A further 40 women predicted to be at a lower risk of fatigue will join a risk score validation group.Measures to assess feasibility include recruitment, retention and completion rates and variation in implementation of the intervention. Process evaluation with intervention providers and users includes fidelity and adherence checks and qualitative interviews to understand how changes in behaviour are initiated and sustained.

Discussion

This feasibility study collates data to both inform the progression to and design of a future definitive trial and to refine the intervention.

Trial registration

ISRCTN 10303368. Registered August 2017 (retrospectively registered); Health and Care Research Wales Clinical Research Portfolio (CRP) registration 31419.

A Review of the Parenteral Nutrition Supply Service in an Irish Neonatal Unit

Background Neonatal Intensive Care (NICU) patients have individual nutritional requirements often requiring Patient Specific Parenteral Nutrition (PSPN). From October 2015, the national PSPN compounding service availability changed from 7 days per week service to 5 days per week (i.e. no weekend and limited bank holiday ordering available). The aim of this study was to examine the introduction of a 5 day only PSPN supply on neonatal patient parenteral nutrition availability in a tertiary NICU. Methods We performed a prospective assessment of the provision of a 5 day rather than 7 day ordering of PSPN over a one month period (June 2017). Results Fifteen neonatal patients received a cumulative 89 days of PN during June 2017. 10 (66%) patients received PSPN during this time period. There was same day availability of PSPN in 62 of 89 days of PN (69%). Conclusion Thorough education and training will help prescribers to make appropriate PSPN ordering decisions. Improvements to available stock bags may reduce the amount of PSPN that is required but a 7 day PSPN ordering service would improve efficient provision of clinically indicated PSPN to premature infants in NICU in Ireland.

The Triangular Sign, a Useful Diagnostic Marker for Biliary Atresia: A Case Series of Three Irish Infants

Background The triangular cord (TC) sign is the appearance of a triangular shaped echogenic density visualised immediately cranial to the portal vein bifurcation on ultrasonographic examination. Several studies have reported that this ultrasonographic sign is a reliable and helpful marker in identifying Biliary Atresia (BA). Aims To report the identification of the TC sign in three infants with BA in the Rotunda Hospital, Dublin. Methods A retrospective chart review was performed to evaluate the clinical presentation and imaging of the three patients with positive TC sign and BA. Discussion Timely, accurate diagnosis of BA is essential to minimise morbidity and optimise patient outcome. The TC is a valuable ultrasonographic sign to aid early diagnosis of BA.

Assessing land use, sedimentation, and water quality stressors as predictors of coral reef condition in St. Thomas, U.S. Virgin Islands

Coral reef condition on the south shore of St. Thomas, U.S. Virgin Islands, was assessed at various distances from Charlotte Amalie, the most densely populated city on the island. Human influence in the area includes industrial activity, wastewater discharge, cruise ship docks, and impervious surfaces throughout the watershed. Anthropogenic activity was characterized using a landscape development intensity (LDI) index, sedimentation threat (ST) estimates, and water quality (WQ) impairments in the near-coastal zone. Total three-dimensional coral cover, reef rugosity, and coral diversity had significant negative coefficients for LDI index, as did densities of dominant species Orbicella annularis, Orbicella franksi, Montastraea cavernosa, Orbicella faveolata, and Porites porites. However, overall stony coral colony density was not significantly correlated with stressors. Positive relationships between reef rugosity and ST, between coral diversity and ST, and between coral diversity and WQ were unexpected because these stressors are generally thought to negatively influence coral growth and health. Sponge density was greater with higher disturbance indicators (ST and WQ), consistent with reports of greater resistance by sponges to degraded water quality compared to stony corals. The highest FoRAM (Foraminifera in Reef Assessment and Monitoring) indices indicating good water quality were found offshore from the main island and outside the harbor. Negative associations between stony coral metrics and LDI index have been reported elsewhere in the Caribbean and highlight LDI index potential as a spatial tool to characterize land-based anthropogenic stressor gradients relevant to coral reefs. Fewer relationships were found with an integrated stressor index but with similar trends in response direction.

Abstract PD4-13: Estrogen receptor-negative breast adenomyoepitheliomas are driven by co-occurring HRAS hotspot and PI3K pathway gene mutations: A genetic and functional analysis

Introduction:Adenomyoepithelioma (AME) of the breast is a rare biphasic tumor, characterized by epithelial and myoepithelial differentiation. Although AMEs have an indolent clinical course, a subset may progress to carcinoma and metastasize. We sought to define the mutational landscape of AMEs and investigate the functional impact of recurrent pathogenic mutations identified in these tumors.

Methods: Thirty-one AMEs were subjected to whole-exome sequencing (WES, n=8) or massively parallel sequencing targeting all coding regions of 410 key cancer genes and intronic and regulatory regions of selected genes (n=23). Somatic genetic alterations were defined using state-of-the-art bioinformatics algorithms. In an additional set of 12 AMEs, Sanger sequencing analysis of HRAS, PIK3CA and AKT1 was performed. Non-tumorigenic estrogen receptor (ER)-negative mammary epithelial cells (i.e. MCF10A, MCF10A with a PIK3CA H1047R mutation knock-in and MCF12A) were utilized for functional studies using both conventional monolayer and three-dimensional (3D) culture assays.

Results: 27 (63%) and 16 (37%) AMEs were ER-positive and ER-negative, respectively. ER-negativity was significantly associated with histologic features predictive of a more aggressive behavior, with a higher number of mutations and copy number alterations, and with a distinct mutational profile as compared to ER-positive AMEs. Of the 27 ER-positive AMEs, 12 cases (44%) harbored PIK3CA hotspot mutations, and 5 PIK3CA wild-type cases displayed E17K AKT1 hotspot mutations. By contrast, of the 16 ER-negative AMEs, 9 (56%), 9 (56%) and 3 (19%) harbored HRAS, PIK3CA (mostly E545K and H1047R hotspots) and PIK3R1 mutations, respectively. Strikingly, all HRAS mutations were restricted to ER-negative AMEs, affected the hotspot codon Q61 (Q61R/K), and all but one co-occurred with PIK3CA or PIK3R1 mutations. In addition, HRAS Q61 hotspot mutations were significantly associated with necrosis (p=0.01) and high mitotic rates (p=0.03). CDKN2A homozygous deletions were also detected only in ER-negative AMEs (19%) and found to be significantly associated with progression to carcinoma (p=0.001). Forced expression of HRAS Q61R in MCF10A and MCF12A cells resulted in i) increased proliferation and transformation, ii) an irregular growth pattern in 3D organotypic cell cultures, iii) partial loss of the epithelial phenotype, and iv) acquisition of myoepithelial differentiation, which was more overt in PIK3CA-mutant MCF10A cells. HRAS Q61Rinduced hyperactivation of the PI3K pathway, but both PI3K and MAPK pathways likely contributed to the RAS-mediated proliferation, which was completely arrested by combined AKT and MEK inhibition.

Conclusion: AMEs are phenotypically and genetically heterogeneous. Whilst pathogenic mutations in PI3K pathway-related genes occur across the spectrum of lesions, HRAS Q61 hotspot mutations are restricted to ER-negative AMEs. Our genomic and functional analyses indicate that HRAS Q61 mutations are driver events in the pathogenesis of ER-negative AMEs and, in conjunction with mutant PIK3CA, may lead to the acquisition of myoepithelial differentiation in breast epithelial cells.

Citation Format: Geyer FC, Li A, Papanastasiou AD, Smith A, Selenica P, Burke KA, Edelweiss M, Wen H-C, Piscuoglio S, Schultheis AM, Martelotto LG, Pareja F, Kumar R, Brandes A, Lozada J, Macedo GS, Muenst S, Terracciano LM, Jungbluth A, Foschini MP, Wen HY, Brogi E, Palazzo J, Rubin BP, Ng CKY, Norton L, Varga Z, Ellis IO, Rakha E, Chandarlapatty S, Weigelt B, Reis-Filho JS. Estrogen receptor-negative breast adenomyoepitheliomas are driven by co-occurring HRAS hotspot and PI3K pathway gene mutations: A genetic and functional analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD4-13.