Identifying oncogenic drivers associated with increased risk of late distant recurrence in postmenopausal, estrogen receptor-positive, HER2-negative early breast cancer: results from the BIG 1-98 study

BACKGROUND

In postmenopausal, estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer, the risk for distant recurrence can extend beyond 5 years of adjuvant endocrine therapy. This study aims to identify genomic driver alterations associated with late distant recurrence.

PATIENTS AND METHODS

Next generation sequencing was used to characterize driver alterations in primary tumors from a subset of 764 postmenopausal estrogen receptor-positive/HER2-negative patients from the BIG 1-98 randomized trial. Late distant recurrence events were defined as ≥5 years from time of randomization). The association of driver alterations with distant recurrence-free interval in early and late time periods was assessed using Cox regression models. Multivariable analyses were carried out to adjust for clinicopathological factors. Weighted analysis methods were used in order to correct for over-sampling of distant recurrences.

RESULTS

A total of 538 of 764 (70%) samples were successfully sequenced including 88 (63%) early and 52 (37%) late distant recurrence events after a median follow up of 8.1 years. In univariable analysis for late distant recurrence, PIK3CA mutations (58.8%) were significantly associated with reduced risk [hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.20-0.82, P = 0.012], whereas amplifications on chromosome 8p11 (10.9%) (HR 4.79, 95% CI 2.30-9.97, P < 0.001) and BRCA2 mutations (2.3%) (HR 5.39, 95% CI 1.51-19.29, P = 0.010) were significantly associated with an increased risk. In multivariable analysis, only amplifications on 8p11 (P = 0.002) and BRCA2 mutations (P = 0.013) remained significant predictors.

CONCLUSIONS

In estrogen receptor-positive/HER2-negative postmenopausal early breast cancer, PIK3CA mutations were associated with reduced risk of late distant recurrence, whereas amplifications on 8p11 and BRCA2 mutations were associated with increased risk of late distant recurrence. The characterization of oncogenic driver alterations may aid in refining treatment choices in the late disease setting, and help identify potential drug targets for testing in future trials.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study

INTRODUCTION

Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach.

MATERIALS AND METHODS

This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery.

RESULTS

The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001).

CONCLUSIONS

According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Abstract ES8-1: Adjuvant endocrine therapy in 2020: It's complicated

Adjuvant endocrine therapy in 2020: It’s complicated Data regarding the use of adjuvant endocrine therapy in patients with hormone receptor-positive early breast cancer has grown over the past decades, and yet still uncertainty remains in management recommendations. In pre-menopausal women, treatment decisions are often driven by estimation of risk of recurrence, measured in terms of clinical and pathological parameters, algorithm-based prognostic modelling derived from breast cancer registries, molecular profiling and gene signature assays. Despite these significant advances, risk of distant disease recurrence is still over-estimated in a significant proportion of women. The addition of ovarian suppression to tamoxifen in pre-menopausal women has been shown to increase rates of both disease-free survival and overall survival than tamoxifen alone, with the use of the steroidal aromatase inhibitor exemestane producing further higher rates of freedom from recurrence. However, the addition of ovarian suppression in this generally low-risk population comes at the cost of increased adverse events and potential to interpose child-bearing years. Further to this, the SOFT/TEXT studies mandated five years of active treatment; little is known as to whether extended treatment beyond those five years would be comparatively equal, better or worse in terms of outcome endpoints.

In the post-menopausal population, the updated ASCO Clinical Practice Guideline suggests that all women with node-positive disease should be offered extended therapy including an aromatase inhibitor for a total of ten years, as well as women with node-negative disease possessing high-risk prognostic factors. The question of how best to identify those women who may fare equally well with de-escalated, shorter therapy remains open. The issue of adverse events and drug-related side effects, particularly in the setting of extended therapy, is relevant and may impact negatively on overall treatment compliance and quality of life. As such, the choice of endocrine therapy remains an important consideration, as is evidence that intermittent administration of aromatase inhibitors may be feasible in selected patients.

CDK4/6 inhibitors, administered in tandem with endocrine therapy, have radically changed the approach to managing metastatic endocrine receptor-positive disease. There is now much interest in moving these agents forward into the neoadjuvant and adjuvant setting, with a number of phase II and III trials ongoing. If positive data is consistently reported in adjuvant studies, this will undoubtedly create another layer of complexity to the clinical management of endocrine-sensitive disease.

Citation Format: A McCartney, A Di Leo. Adjuvant endocrine therapy in 2020: It's complicated [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr ES8-1.

Palbociclib as single agent or in combination with the endocrine therapy received before disease progression for estrogen receptor-positive, HER2-negative metastatic breast cancer: TREnd trial

Background

The activity of palbociclib as a single agent in advanced breast cancer has not been extensively studied, with the only available clinical data limited to heavily pretreated patients. Preclinical data suggests palbociclib may partially reverse endocrine resistance, though this hypothesis has not been evaluated in previous clinical studies. This phase II, open-label, multicenter study examined the activity of palbociclib monotherapy, as well as palbociclib given in combination with the same endocrine therapy (ET) that was received prior to disease progression, in postmenopausal women with moderately pretreated, estrogen receptor-positive, HER2 negative advanced breast cancer.

Patients and methods

Eligible women with advanced disease which had progressed on one or two prior ETs were randomized 1 : 1 to receive either palbociclib alone, or palbociclib in combination with the ET as previously received. Primary end point was clinical benefit rate (CBR); secondary end points included progression-free survival (PFS).

Results

Between October 2012 and July 2016, a total of 115 patients were randomized. The CBR was 54% [95% confidence interval (CI): 41.5-63.7] for combination therapy, and 60% (95% CI: 47.8-72.9) for monotherapy. Median PFS was 10.8 months (95% CI: 5.6-12.7) for combination therapy, and 6.5 months (95% CI: 5.4-8.5) for monotherapy [hazard ratio (HR) 0.69; 95% CI: 0.4-1.1, exploratory P-value = 0.12]. Exploratory analyses revealed the PFS advantage for combination therapy was seen in the subgroup of patients who received prior ET for >6 months (HR 0.53; 95% CI: 0.3-0.9, exploratory P-value = 0.02), but not in those who received prior ET for ≤6 months.

Conclusion

Palbociclib has clinical activity as a single agent in women with moderately pretreated, oestrogen receptor-positive, HER2-negative advanced breast cancer. Palbociclib may have potential to reverse endocrine resistance in patients with a history of previous durable response to ET.

Clinical trial information

NCT02549430.

Clinical significance of CD73 in triple-negative breast cancer: multiplex analysis of a phase III clinical trial

Background

CD73 is an ecto-enzyme that promotes tumor immune escape through the production of immunosuppressive extracellular adenosine in the tumor microenvironment. Several CD73 inhibitors and adenosine receptor antagonists are being evaluated in phase I clinical trials.

Patients and methods

Full-face sections from formalin-fixed paraffin-embedded primary breast tumors from 122 samples of triple-negative breast cancer (TNBC) from the BIG 02-98 adjuvant phase III clinical trial were included in our analysis. Using multiplex immunofluorescence and image analysis, we assessed CD73 protein expression on tumor cells, tumor-infiltrating leukocytes and stromal cells. We investigated the associations between CD73 protein expression with disease-free survival (DFS), overall survival (OS) and the extent of tumor immune infiltration.

Results

Our results demonstrated that high levels of CD73 expression on epithelial tumor cells were significantly associated with reduced DFS, OS and negatively correlated with tumor immune infiltration (Spearman's R= -0.50, P < 0.0001). Patients with high levels of CD73 and low levels of tumor-infiltrating leukocytes had the worse clinical outcome.

Conclusions

Taken together, our study provides further support that CD73 expression is associated with a poor prognosis and reduced anti-tumor immunity in human TNBC and that targeting CD73 could be a promising strategy to reprogram the tumor microenvironment in this BC subtype.

Abstract P4-13-13: Meta-analyses of visceral versus non-visceral metastases treated by AI & SERD agents as 2nd line endocrine therapy (ET) for HR+ breast cancer (BC)

There is a prevailing belief that ET for HR+ advanced BC is not as effective in patients with visceral metastases (VM) compared to non-visceral metastases (nVM), particularly with later lines of ET. Recently fulvestrant 500mg (Ful 500), has been reported to have greater efficacy in nVM compared to i) VM treated by Ful 500 but also compared to ii) nVM treated by Ful 250 (2nd line) and iii) nVM treated by aromatase inhibitor (AI), anastrozole (1st Line) – implying both site and agent related efficacy. Absence of significant overall survival (OS) difference in PALOMA 3 (2nd line) has increased the debate regarding when to add CDK 4/6is to ET, especially given the OS advantage for Ful 500 monotherapy in the 1st & 2nd line settings.

Patients & Methods: Anonymised, individual patient level data was obtained from randomised controlled trials (RCTs) involving AI & SERD used as mono-theraphy in 2nd or 3rd Line setting in known HR+ BC. All the trials were Phase 3 double-blind, placebo RCTs. All were rigorously assessed for clinical benefit (CB), progression free survival (PFS), duration of CB (DoCB) and OS. Details of the studies, types of ET and patient numbers are shown in the Table.

Results: Outcome data is presented for each study and then summarised under AI, SERD (Ful 250 or 500) and 'all Ets combined'. Odds ratios (Ors) & hazard ratios (HRs) for VM versus nVM by endocrine agents are shown in the Table.

AgentStudyTotal Pats.HR+ Pats.CBRPFSOSDoCBAI(n)(n)OR (95%Cis)HR (95%Cis)HR (95%Cis)HR (95%Cis)Exe00202301831.181.441.271.50Exe00211931681.151.951.832.12AnaEFECT3403360.941.521.201.10AnaSOFEA2492491.291.181.051.41subtotal7636871.11 (0.84-1.48)1.47*** (1.22-1.79)1.21* (1.01-1.45)1.43** (1.10-1.86)SERDFul 25000202191601.791.701.401.23Ful 25000212041771.281.811.322.06Ful 250EFECT3513450.791.401.311.03Ful 250SOFEA2312310.701.171.242.22Ful 250CONFIRM1521521.131.071.510.84Subtotal9268341.05 (0.75-1.45)1.39*** (1.16-1.67)1.34*** (1.14-1.57)1.36 (0.93-1.98)SERDFul 500CONFIRM1441442.24 (1.12-4.48)1.30 (0.90-1.87)1.33 (1.14-1.57)0.97 (0.55-1.66)All ETsTotal183316651.13 (0.92-1.39)1.42*** (1.26-1.59)1.28*** (1.14-1.44)1.35** (1.09-1.66)

[Pats=Patients; (n)=number; CBR-Clinical Benefit Rate; p-values p&lt;0.05*, p&lt;0.01**, p&lt;0.001***]

Median PFS (months) for nVM for AI, SERD250, SERD500 & ‘all Ets combined’ were 5.4, 5.5, 11.0 & 5.5 respectively: for VM they were 2.9, 3.5, 5.5 & 3.2 respectively.

Median OS (months) for nVM for AI, SERD250, SERD500 & ‘all Ets combined’ was 24.2, 26.0, 35.4 & 25.4 respectively: for VM the figures were 22.8, 20.8, 26.4 & 22.0 respectively.Conclusions:1) In the 2nd line HR+ setting AI & Ful 250 both significantly increased PFS & OS in nVM versus VM. Longer PFS appears due to longer duration of control (DoCB) than increasing the number of patients responding (CBR).

2) Median OS for nVM ranged from 24 – 35 months versus 20.8-26.4 months for VM: for the majority of patients the 2nd line ET setting is not ‘immediately life threating’ and ET is therefore an option to consider.

3) These data on site of disease (nVM vs VM) contribute to the selection of which patients should receive endocrine mono- and which endocrine combination therapy (ie plus mTORi or CDK4/6i) in the second line setting.

Citation Format: Robertson JFR, Di Leo A, Johnston S, Chia S, Bliss J, Bradbury I, Campbell C. Meta-analyses of visceral versus non-visceral metastases treated by AI & SERD agents as 2nd line endocrine therapy (ET) for HR+ breast cancer (BC) [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 P4-13-13.

Abstract PD5-09: Immune parameters associated with survival in triple negative and HER2-positive breast cancer patients with 10 years of follow-up

The clinical utility of tumor-infiltrating lymphocytes (TIL) is actively being investigated in breast cancer (BC). It is unclear whether TIL spatial location and organization in tertiary lymphoid structures (TLS) have an impact on prognosis. Additionally, the significance of PD-1 and PD-L1 expression is being debated due to conflicting data from several studies. We hypothesize that the presence, extent and spatial location of multiple immune biomarkers, reflecting ongoing immune responses, will be consistently associated with a good prognosis in highly infiltrated BC [triple-negative (TNBC) and HER2+].

The relationship between these immune biomarkers and clinical outcome was examined in the TNBC and HER2+ cohorts of node-positive BC patients enrolled in the BIG 02-98 adjuvant phase III trial with available material for immunohistochemical (IHC) labeling (N=113 and N=136, respectively). HER2+ patients did not receive trastuzumab. Dual IHC staining was performed on full-face consecutive tissue sections. Scoring was independently performed by two pathologists, blinded to the clinical data, and included: global, intratumoral and stromal TIL and TLS, assessed on CD3/CD20 slides; the percentage and location of PD-1 and PD-L1 expression, assessed on PD-1/PD-L1 slides. TIL were considered as a categorical variable with different cut-offs used for each parameter and for each cohort (TNBC and HER2+). Invasive disease-free survival (I-DFS) and overall survival (OS) were analyzed (median follow-up: 10 years). Cox proportional hazard models were used for survival analyses.

The TNBC cohort revealed an association between global TIL and outcome [adjusted hazard ratio (HR) for I-DFS: 0.27 (0.15-0.51); OS: 0.26 (0.13-0.53)]. Similar results were observed for stromal and intratumoral TIL. PD-L1 expression within TLS was an independent predictor of OS, after adjustment for tumor size and age [HR: 0.30 (0.09-0.99)]. Multivariate analysis reveals this effect was principally driven by high stromal TIL (&gt;17.5% based on CD3/CD20 assessment) (χ2 OS: p=0.009). In contrast, no significant prognostic associations were found in the overall HER2+ cohort. However high T cell TIL were associated with improved I-DFS and OS in the ER-/HER2+ group [I-DFS: 0.34 (0.14-0.80); OS: 0.32 (0.12-0.86)] and stromal TIL were associated with improved I-DFS in the ER+/HER2+ group [HR: 0.29 (0.09-0.94)] (univariate analyses). No significant associations between the number of TLS nor the expression of PD-1 with outcomes were observed in either cohorts.

The presence of PD-L1+ TLS, driven by high baseline TIL, was associated with an excellent prognosis in node-positive TNBC. This observation might reflect specific immune activities taking place in these mini lymph node-like structures adjacent to the tumor bed where specific antitumor memory immune responses could be generated. No different prognostic impact was observed when analyzing TIL spatial location. Although the statistical power of the study might be limited, in line with previous findings our data reveal that, among the immune parameters evaluated, TIL are the strongest predictor of outcome in TNBC, while PD-L1+ TLS could be a new and important parameter that requires further investigation.

Citation Format: Solinas C, de Wind A, Van den Eynden G, Ameye L, Garaud S, De Silva P, Boisson A, Noel G, Langouo Fontsa M, Buisseret L, de Azambuja E, Francis PA, Di Leo A, Crown JP, Sotiriou C, Larsimont D, Paesmans M, Piccart-Gebhart M, Willard-Gallo K. Immune parameters associated with survival in triple negative and HER2-positive breast cancer patients with 10 years of follow-up [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 PD5-09.

Abstract P6-09-02: Effects of palbociclib on thymidine kinase-1 (TK1) in hormone receptor positive (HR+) breast cancer cell lines

Introduction: TK1 plays a crucial role in DNA synthesis and is a well-established marker of cell proliferation. We and others have previously described the potential role of TK1 activity (TKa) as predictive biomarker of response to endocrine therapy in HR+/HER2 negative metastatic breast cancer patients. TK1 synthesis is regulated by the E2F pathway, the target pathway of CDK4/6 inhibitors, and TKa has recently been reported as a potential circulating pharmacodynamic marker of CDK4/6 inhibition in breast cancer. However, modulations of TK1 levels and activity during palbociclib treatment and in the development of treatment resistance are unknown. Here, we report how TK1 expression and TKa are modulated in response to palbociclib in a panel of HR+ breast cancer cell lines: both palbociclib-sensitive (PDS) and with acquired resistance to (PDR).

Material and methods: We used a panel of 7 PDR HR+ breast cancer models previously developed in our lab via chronic exposure of parental cells (MCF7, T47D, ZR75-1, BT474, MDAMB361 and two MCF7 endocrine resistant derivatives) to escalating doses of palbociclib, from a Starting Treatment Concentration (STC) of 50 nM or 350 nM according to the cell line, up to 1 μM. We analyzed gene expression profiles of PDS cells treated with drug vehicle (DMSO) as a control or palbociclib at STC for 3 days, and PDR cells grown with palbociclib 1 μM. Cell proliferation was assessed by methylene blue assay in MCF7 and BT474 PDS and PDR treated for 3, 6 and 9 days with DMSO, palbociclib STC and 1 μM. In parallel, TKa was measured in cell lysates at 3 days of treatment using the DiviTumTM assay (Biovica, Sweden).

Results: Among E2F target genes, gene expression data demonstrated that TK1 was one of the most differentially expressed genes between PDR and PDS treated cells. In PDS cells compared to control, treatment with palbociclib resulted in reduced TK1 expression, with the HER2 positive models (BT474 and MDAMB361) showing the highest reduction. In PDR cells, TK1 expression was higher, but remained slightly inhibited compared to untreated PDS cells. TKa was significantly reduced in PDS cells treated with palbociclib for 3 days compared to vehicle (p&lt;0.05). TKa response to palbociclib was more dramatic in BT474 cells as compared to MCF7. As expected, palbociclib inhibited cell proliferation in PDS models, with a significant reduction observed only after 6 days of treatment, suggesting that TKa may be an early marker of growth inhibition in response to palbociclib. No significant alterations in TKa were observed in PDR cells, at any dose of palbociclib. Similarly, proliferation rate was not affected by palbociclib in PDR cells.

Conclusions: TK1 expression and activity are regulated by palbociclib in HR+ breast cancer cell lines, particularly in HER2 positive models. Ongoing studies of TKa in patients treated with palbociclib will assess the role of TKa as a circulating biomarker for predicting and monitoring response to CDK4/6 inhibitors.

Citation Format: Bonechi M, Migliaccio I, Benelli M, Romagnoli D, Bergqvist M, Mattsson K, Boccalini G, Capaccioli G, De Luca F, Galardi F, Biagioni C, Risi E, McCartney A, Rossi L, Osborne CK, Schiff R, De Angelis C, Guarducci C, Di Leo A, Malorni L. Effects of palbociclib on thymidine kinase-1 (TK1) in hormone receptor positive (HR+) breast cancer cell lines [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 P6-09-02.

Lessons learned from 227 biological meshes used for the surgical treatment of ventral abdominal defects

PURPOSE

The advantages of biological meshes for ventral hernia repair are still under debate. Given the high financial cost, the proper indications for biological meshes should be clarified to restrict their use to properly selected patients.

METHODS

A retrospective database was instituted to register all cases of abdominal wall defect treated with biological meshes from 1/2010 to 3/2016.

RESULTS

A total of 227 patients (mean age: 64 years) whose ventral abdominal defects were reconstructed with a biological mesh were included in the study. Patients were divided according to the 2010 four-level surgical-site complication risk grading system proposed by the Ventral Hernia Working Group (VHWG): Grade 1 (G1, 12 cases), Grade 2 (G2, 68 cases), Grade 3 (G3, 112 cases), and Grade 4 (G4, 35 cases). The surgical site complication rate was higher in patients with one or more risk factors (33.6% vs 19% in patients with no risk factors) (P = 0.68). Statistically significant risk factors associated with the onset of one or more postoperative surgical site complications included: diabetes, coronary artery disease, immunosuppression, and obesity. Recurrence was more common in patients with surgical site complications and mainly associated with infection (38.9%) and wound necrosis (44.4%), and in cases of inlay positioning of the mesh (36%).

CONCLUSIONS

Due to their high costs, biological mesh should not be used in G1 patients. In infected fields (G4), they should only be used if no other surgical solution is feasible. There is a clear need to prospectively evaluate the performance of biological meshes.

Proximate, fatty acids and metals in edible marine bivalves from Italian market: Beneficial and risk for consumers health

Seafood is recognized as a healthy food choice due to high contents of essential nutrients, including polyunsaturated fatty acids (PUFAs) of the n-3 family. However, seafood is often contaminated by toxic compounds, which have adverse effects on human health. The aim of this study was to provide information about the percentage of edible part, condition index and the benefit and risk for human consumers health associated to the consumption of eight bivalve species (Flexopecten glaber, Mimachlamys varia, Modiolus barbatus, Mytilus galloprovincialis, Ostrea edulis, Ruditapes philippinarum, Solen marginatus and Venus verrucosa) of high commercial value, purchased from Taranto local fish markets. High percentage of edibility and condition index were found in all analysed species. The relatively high protein content, low levels of lipid and high percentage of healthy n-3 PUFAs make M. varia, O. edulis, S. marginatus, M. galloprovincialis, M. barbatus more suitable for benefit to consumers. Provisional tolerable weekly intake and hazard index calculated on the basis of trace metals in edible tissues, indicated specific recommendations for a responsible daily consumption of shellfish. For the most part of studied species, the estimated balance between beneficial and risk for consumers recommend a daily portion (RDP) lesser of 60 g/person/day than M. galloprovincialis, O. edulis and R. philippinarum (≥60 g/person/day). Careful risk-benefit considerations should promote seafood consumption while minimizing exposure to toxic contaminants.

An Intensive Treatment with Mitoxantrone and Ifosfamide in Second-Line Therapy of Epithelial Ovarian Cancer

Aims and background

Both mitoxantrone (DHAD) and ifosfamide (IFO) have given promising results when administered as single agents in advanced ovarian cancer pretreated with platinum compounds. The aim of this I.T.M.O. group pilot trial was to evaluate, in a selected population of ovarian cancer patients, the efficacy and tolerability of the following intensive second-line regimen: DHAD, 12 mg/m2 i.v., day 1; IFO, 4,000 mg/m2 i.v., days 1 and 2; Mesna, 800 mg/m2 i.v. t.i.d., days 1 and 2. Filgrastim (5 μg/kg/day i.m.) was given from day 6 to day 19 to reduce the expected neutropenia. Cycles were repeated every 21 days.

Methods

Nineteen platinum-pre-treated patients were enrolled and 14 were evaluated for tumor response; the disease of 5 patients was not measurable clinically or radiologically.

Results

Seven responses were observed (3 CRs), with a median response duration of 5 months. The median time to treatment failure and overall survival for all 19 patients was respectively 8 and 13 months. Anemia was observed in all of the treated patients (grade 3–4 in 9 cases). Only 6 of the 19 patients ended the five planned cycles of chemotherapy without any delay.

Conclusions

Although DHAD plus IFO induced a considerable number of objective responses, the limited response duration time to treatment failure, and overall survival as well as the reported side effects suggest that this is not a recommended regimen for the palliative treatment of ovarian cancer patients undergoing second-line chemotherapy.

High efficacy of direct-acting anti-viral agents in hepatitis C virus-infected cirrhotic patients with successfully treated hepatocellular carcinoma

BACKGROUND

The efficacy of direct-acting anti-viral (DAA) therapy in patients with a history of hepatocellular carcinoma (HCC) is unknown.

AIM

We prospectively evaluated whether previously treated HCC affects DAA efficacy in a large real-life cohort of cirrhotic patients.

METHODS

From January to December 2015 all consecutive HCV mono-infected patients with cirrhosis and/or history of HCC attending 10 Italian tertiary liver centres were enrolled. Baseline characteristics and response to therapy were recorded. 1927 patients were enrolled (mean age: 62.1 ± 10.9 years; 1.205 males). Genotype 1 was the most frequent (67.9%) followed by genotypes 3 (12.4%), 2 (11.2%) and 4 (8.6%). 88.4% and 10.9% of cases were classified Child A and B, respectively, and 14 (<1%) cases were classified Child C. Ascites and hepatic encephalopathy occurred in 10.7% and 3.2% of patients, respectively. Varices were detected in 39.3% of patients. Suboptimal and optimal treatment was prescribed: 15.9% of patients received sofosbuvir/simeprevir, 33.4% sofosbuvir/ledipasvir, 20.2% a Viekirax + Exviera regimen, 15.7% sofosbuvir/ribavirin, 9.9% sofosbuvir/daclatasvir and 3.4% Viekirax; 1.3% of patients received an interferon-based regimen.

RESULTS

The sustained virologic response (SVR) rate at intention-to-treat analysis was 95.1%. It differed significantly across Child classes, that is, 96.3%, 86.1% and 71.4% Child A, B and C, respectively (P < 0.0001) and across genotypes (P = 0.002). The SVR rate did not differ between patients with (95.0%) and those without previous HCC (95.1%). At multivariable analysis, SVR was significantly associated with HCV genotype, Child class.

CONCLUSION

This large real-life study proves that the efficacy of DAA in cirrhotic patients is not impaired by successfully treated HCC.

Adenocarcinoma of Unknown Primary Site with Bone Marrow and Orbital Metastases Suggestive of a Prostatic Origin

Prostate cancer may occasionally present as an adenocarcinoma with an undetermined primary site. We report a case in which bone marrow invasion and orbital metastasis were the first evidence of malignancy. Recognition of metastatic prostate cancer is important since it can be managed safely and effectively with hormonal therapy.

Systematic review with meta-analysis: de novo non-alcoholic fatty liver disease in liver-transplanted patients

BACKGROUND

De novo non-alcoholic fatty liver disease (NAFLD) in liver-transplanted patients for cirrhosis not due to non-alcoholic steatohepatitis (NASH) is becoming a growing phenomenon.

AIMS

We performed a systematic review and evaluated the prevalence of this event and possible associated factors.

METHODS

A literature search in medical databases (PubMed, MEDLINE/OVIDSP, Science Direct and EMBASE) was performed in March 2017. Relevant publications were identified in most important databases. We estimated the pooled prevalence of NAFLD and NASH in patients with liver transplant. The data have been expressed as proportions/percentages, and 95% confidence intervals (CI) were calculated, using the inverse variance method. Odd ratios (OR) and 95% confidence intervals (95% CI) were estimated.

RESULTS

Twelve studies were selected, enrolling 2166 subjects overall undergoing post-liver transplant biopsy. The pooled weighted prevalence of de novo NAFLD was 26% (95% CI 20%-31%). The pooled weighted prevalence of NASH was 2% (95% CI 0%-3%). The highest prevalences of de novo NAFLD were found for patients transplanted for alcoholic cirrhosis (37%) and cryptogenic cirrhosis (35%) and for patients taking tacrolimus (26%). Tacrolimus showed a risk of NAFLD similar to ciclosporin (OR = 1.02, 95% CI 0.3-3.51).

CONCLUSIONS

Patients undergoing liver transplant are more prone to experience diabetes, hypertension or dyslipidaemia, and NAFLD may be an important element in this context. In this study, we show how the prevalence of NASH tends to remain significant and similar to the general population. Moreover, this study suggests a possible association with specific transplant indications. Further studies are required to confirm these findings.

Abstract P1-10-06: A randomized phase II trial evaluating the endocrine activity and efficacy of neoadjuvant degarelix versus triptorelin in premenopausal patients receiving letrozole for primary endocrine responsive breast cancer (TREND; IBCSG 41-13)

Background: Neoadjuvant endocrine therapy (NET) with gonadotropin-releasing hormone (GnRH) agonist and aromatase inhibitors is effective in selected premenopausal patients (pts). Degarelix, an antagonist of GnRH, has immediate onset of action through binding to GnRH receptors in the pituitary gland and thereby suppressing the production of LH and FSH. Its suppressing activity in premenopausal women might be faster and free of estrodial breakthrough on continued treatment compared with a GnRH angonist, and thereby provide significant clinical value for pts who are candidates for short-term NET.

Methods: Eligible pts were premenopausal women with cT2-4b, any nodal stage, ER and PgR &gt;50%, HER2-negative (by IHC and/or ISH) breast cancer who were not candidates for breast conserving surgery. Premenopausal status was determined locally with estradiol (E2) levels &gt;54 pg/mL (or &gt;198 pmol/L), measured within 14 days prior to randomization. Pts were randomized 1:1 to Triptorelin (T) 3.75 mg i.m. on day 1 of every cycle or Degarelix (D) 240 mg s.c. given as two injections of 120 mg on day 1 of cycle 1, then 80 mg s.c. on day 1 of cycles 2-6 with letrozole (L) 2.5 mg/day for 6 cycles. Each cycle was 28 days. Definitive surgery was performed within 2-3 weeks after the last administration of T or D. Serum was collected prior to the first injection (baseline), 24 and 72 hours, 7 and 14 days, then prior to injection on day 1 of cycles 2-6. The primary endpoint was time to optimal ovarian function suppression (OFS) calculated as time from the first injection of D or T to the first assessment of centrally assessed 17-β-estradiol (E2) level in the range of optimal OFS (≤2.72 pg/mL or ≤10 pmol/L) during the 6 cycles of NET. The trial had 90% power to detect a difference using a logrank test, 2-sided α=0.05. Secondary endpoints included tolerability, Ki67changes, PEPI score, best overall response. NCT02005887

Results: TREND completed accrual of 51 pts in January 2017. A preliminary analysis based on the first 45 pts is reported here. 89% of patients were ≥40 yrs, 76% had T1-2 and 22% T3 tumors, and 51% were node-positive. Dominant histology type was ductal (93%). The table summarizes centrally-assessed E2 according to treatment at baseline and for the first 5 assessment time points indicating immediate suppression for the D+L arm. E2 levels on day 1 of cycles 2-6 were all below the limit of quantification (0.625 pg/mL) for the D+L arm. For the T+L arm continued OFS was not maintained in 4 pts.

 BaselineCycle 1Cycle 2Day:01371429No. Pts      D+L222221212221T+L232321232222Median (IQR)     D+L96.2 (64.2,206.8)10.1 (4.0,21.8)0.6 (0.6,1.0)0.6 (0.6,0.6)0.6 (0.6,0.6)0.6 (0.6, 0.6)T+L85.1 (49.7,118.0)37.4 (17.9,59.2)12.8 (7.7,23.8)9.0 (1.2,29.7)0.6 (0.6,1.4)0.6 (0.6, 0.6)

Conclusion: Evidence from this first analysis demonstrates rapid and maintained OFS with the combination of D+L as a NET in premenopausal breast cancer patients. The final analysis of the total population, including secondary endpoints, will be presented at the symposium.

Citation Format: Colleoni M, Gray K, Munzone E, Dellapasqua S, Zamagni C, Gianni L, Johansson H, Viale G, Kammler R, Maibach R, Rabaglio-Poretti M, Di Leo A, Coates AS, Gelber RD, Regan MM, Goldhirsch A. A randomized phase II trial evaluating the endocrine activity and efficacy of neoadjuvant degarelix versus triptorelin in premenopausal patients receiving letrozole for primary endocrine responsive breast cancer (TREND; IBCSG 41-13) [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 P1-10-06.

Abstract PD6-07: Clinical significance of CD73 expression in triple-negative breast cancer from the BIG 02-98 adjuvant phase III clinical trial

Background: CD73 is an ecto-enzyme that promotes tumor immune escape through the production of immunosuppressive extracellular adenosine in the tumor microenvironment. Several CD73 inhibitors and adenosine receptor antagonists are being evaluated in phase I clinical trials.

Objective: To investigate the prognosis significance of CD73 in human triple-negative breast cancer.

Design and setting: This is a prospective-retrospective biomarker analysis. Using multiplex immunofluorescence and image analysis, we assessed CD73 protein expression on tumor cells, tumor-infiltrating leukocytes and stromal cells on full-face sections from formalin-fixed paraffin-embedded primary breast tumors.

Participants: 122 samples of triple-negative breast cancer from the BIG 02-98 adjuvant phase III clinical trial were included in our analysis. This trial compared the addition of taxanes to anthracyclines-based chemotherapy in node-positive breast cancer.

Results: Our results demonstrated that high levels of CD73 expression on epithelial tumor cells were significantly associated with reduced disease-free survival (DFS) and overall survival (OS) in patients with triple-negative breast cancer. Using the median as a threshold between low and high levels of CD73 on epithelial cells, hazard ratios (HR) adjusted for grade, number of positive lymph nodes and tumor size, were of 2.21 (95% confidence interval (CI): 1.15-4.25); p=0.02 for DFS and of 2.47 (95%CI: 1.21-5.07); p=0.01 for OS. CD73 expression negatively correlated with tumor immune infiltration (Spearman's R= -0.50, p&lt;0.0001). Patients with high levels of CD73 and low levels of tumor-infiltrating leukocytes had the worse clinical outcome (HR: 4.24 (1.90-9.45), p&lt;0.001 for DFS, HR: 3.91 (1.65-9.31), p=0.002 for OS) compared to patients with low CD73 and high tumor-immune infiltration. Flow cytometric analysis of tumor-infiltrating leukocytes revealed a high frequency of CD73-expressing B cells and higher CD73 expression on tumor-infiltrating myeloid cells and natural killer cells compared to peripheral blood.

Conclusion and relevance: Taken together, our study provides further support that CD73 expression is associated with a poor prognosis and reduced anti-tumor immunity in human triple-negative breast cancer and that targeting CD73 could be a promising strategy to reprogram the tumor microenvironment in this breast cancer subtype.

Citation Format: Buisseret L, Pommey S, Allard B, Garaud S, Bergeron MA, Cousineau I, Ameye L, Paesmans M, Crown JPA, Di Leo A, Piccart-Gebhart M, Willard-Gallo K, Sotiriou C, Stagg J. Clinical significance of CD73 expression in triple-negative breast cancer from the BIG 02-98 adjuvant phase III clinical trial [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 PD6-07.

Abstract P5-18-01: Extended continuous vs intermittent adjuvant letrozole in postmenopausal women with lymph node-positive, early breast cancer (IBCSG 37-05/BIG 1-07 SOLE): Impact on patient-reported symptoms and quality of life

Background: SOLE efficacy results presented at ASCO 2017 showed that extended intermittent vs continuous letrozole for 5 years did not improve disease-free survival in postmenopausal women who had received 4-6 years of adjuvant endocrine therapy for hormone-receptor positive (HR+), lymph-node positive breast cancer. Previous studies showed that the burden by symptoms related to endocrine therapy can be substantial. Even if symptoms improve during the treatment course, extending treatment implies continuation of symptoms. We compared differences in patient-reported symptoms (PRS) and quality of life (QoL) between extended continuous and intermittent letrozole over the first two years of trial treatment.

Methods: From Nov 2007 to Dec 2010, 956 postmenopausal women who were disease-free following 4-6 years of prior adjuvant endocrine therapy for HR+, node-positive breast cancer were enrolled in the QoL substudy of the randomized phase III trial SOLE at selected centers. Patients receive extended continuous letrozole (2.5 mg daily) for 5 years or intermittent letrozole, taken for the first 9 months of years 1-4, and 12 months in year 5. 955 patients completed the 18-item Breast Cancer Prevention Trial (BCPT) Symptom Scales and further symptom-specific and global QoL indicators at baseline, and at 6, 12, 18 and 24 months after randomization. Differences in change of PRS and QoL from baseline between the two administration schedules were tested at 12 and 24 months for 8 symptom scales, 4 additional symptom and 4 global QoL indicators using mixed models with repeated measures.

Results: Small changes in PRS and QoL scores were observed between baseline and 12 months after randomization, i.e. at the end of the first treatment-free interval in the intermittent arm. These changes showed a consistent pattern of greater worsening for patients receiving continuous compared to patients receiving intermittent letrozole. Patients receiving continuous letrozole reported a significantly greater worsening in vaginal problems (p&lt;.02), musculoskeletal pain (p&lt;.03), sleep disturbance (p&lt;.01), physical wellbeing (p&lt;.01) and mood (p&lt;.03). At 24 months (after 2nd treatment-free interval) patients with intermittent letrozole reported a greater improvement in hot flushes (p&lt;.03) than those with continuous letrozole. Changes in the other outcomes did not significantly differ between arms at 24 months.

Conclusion: Although changes in PRS and QoL were small, there was a consistent pattern favoring the intermittent arm. For several symptoms and global QoL indicators, significantly less worsening was observed with the intermittent administration, mainly during the first year of extended treatment, due to small improvements during the treatment-free interval. Froma QoL perspective, women who suffer from endocrine side-effects in the extended setting may benefit from an intermittent administration.

Citation Format: Ribi K, Luo W, Colleoni M, Karlsson P, Chirgwin J, Aebi S, Jerusalem G, Neven P, Di Lauro V, Gomez HL, Ruhstaller T, Abdi E, Di Leo A, Müller B, Maibach R, Gelber RD, Goldhirsch A, Coates AS, Regan MM, Bernhard J. Extended continuous vs intermittent adjuvant letrozole in postmenopausal women with lymph node-positive, early breast cancer (IBCSG 37-05/BIG 1-07 SOLE): Impact on patient-reported symptoms and quality of life [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 P5-18-01.

Abstract P5-21-02: Efficacy and safety of abemaciclib in patients with liver metastases in the MONARCH 1, 2, and 3 studies

Background:

Abemaciclib is an oral, selective inhibitor of cyclin-dependent kinases 4 & 6 that is dosed on a twice daily continuous schedule. In patients (pts) with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (ABC), abemaciclib has demonstrated clinical efficacy with a tolerable safety profile when administered as monotherapy in MONARCH 1 (NCT02102490), in combination with fulvestrant in MONARCH 2 (NCT02107703), and in combination with non-steroidal aromatase inhibitors (NSAI) in MONARCH 3 (NCT02246621). Inducing tumor response and delaying disease progression is of critical need in pts with liver metastases (mets).

Methods:

An exploratory subgroup analysis was conducted in pts with liver mets at baseline across the MONARCH 1, 2, and 3 studies. All pts had HR+, HER2- ABC. The primary endpoint of MONARCH 1 was objective response rate (ORR), and the primary endpoint of MONARCH 2 and 3 was investigator-assessed progression-free survival (PFS). Analysis methods for these endpoints were previously described. Key enrollment criteria and dosing information are listed in Table 1.

Table 1. Eligibility criteria and dosing information for the MONARCH 1, 2, and 3 studiesKey enrollment criteriaMONARCH 1MONARCH 2MONARCH 3Prior endocrine therapyProgressed on or after ETProgressed while receiving adjuvant or first-line ET, or ≤ 12 months from the end of adjuvant ETET naïve or disease relapse &gt;12 months after (neo)adjuvant ETChemotherapy regimens in advanced setting1 or 200Visceral crisisNo restrictionNot permittedNot permittedDose and Schedule   abemaciclib200 mg, twice daily, continuous150 mg1, twice daily, continuous150 mg, twice daily, continuousfulvestrant-500 mg, per label-anastrozole2--1 mg, dailyletrozole2--2.5 mg, daily1post-amendment; 2physician's choice of NSAI (anastrozole or letrozole); ET: endocrine therapy

Results:

Efficacy results of pts with liver mets are described in Table 2. The most frequent adverse events observed in pts with liver mets in MONARCH 1 were diarrhea, nausea, and fatigue and in the abemaciclib arms of MONARCH 2 and 3 were diarrhea, neutropenia, and nausea.

Table 2. PFS and response rates of pts with liver mets in MONARCH 1, 2, and 3 MONARCH 1MONARCH 2 abemaciclib armMONARCH 2 placebo armMONARCH 3 abemaciclib armMONARCH 3 placebo armPts with liver mets, n93115594830PFS, HR (95% CI)N/A.45 (.31, .64).47 (.25, .87)Median PFS, months5.611.63.115.07.2ORR, n (%)20 (21.5)54 (47.0)9 (15.3)26 (54.2)6 (20.0)CBR, n (%)39 (41.9)77 (67.0)21 (35.6)32 (66.7)12 (40.0)CBR: clinical benefit rate (complete response [CR] + partial response [PR] + stable disease ≥6 months); HR: hazard ratio; ORR: objective response rate (CR+PR); PFS: progression-free survival; pts: patients

Conclusions:

The results suggest that the combination of abemaciclib and endocrine therapy was an effective treatment option in pts with liver metastases, a population deriving modest benefit from single-agent endocrine therapy. Tolerability results were generally consistent with the safety populations previously reported for each study.

Citation Format: Di Leo A, Dickler M, Sledge GW, Toi M, Forrester T, Nanda S, Koustenis A, Bourayou N, Johnston S. Efficacy and safety of abemaciclib in patients with liver metastases in the MONARCH 1, 2, and 3 studies [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 P5-21-02.

Abstract PD5-09: Fulvestrant for hormone receptor-positive advanced breast cancer in patients with visceral vs non-visceral metastases: Findings from FALCON, FIRST, and CONFIRM

BACKGROUND

Patients with hormone receptor-positive (HR+) locally advanced or metastatic breast cancer (LA/MBC) and non-visceral metastases (non-VM) generally have a better prognosis than patients with visceral metastases (VM). However, in the absence of visceral crisis, endocrine therapy (ET) remains an effective treatment option in both patient groups. This descriptive analysis examined the treatment effect of fulvestrant 500 mg vs comparators in postmenopausal patients with HR+ LA/MBC, with or without VM.

METHODS

Three randomized studies of fulvestrant 500 mg for postmenopausal HR+ LA/MBC were included. The Phase 3 FALCON study (NCT01602380) compared fulvestrant 500 mg with anastrozole in patients without any prior ET (n=462; fulvestrant 500 mg: 58.7% with VM; anastrozole: 51.3% with VM). The Phase 2 FIRST study (NCT00274469) compared fulvestrant 500 mg with anastrozole in patients who had not received ET for advanced disease (n=205; fulvestrant 500 mg: 47.1% with VM; anastrozole: 56.3% with VM). The Phase 3 CONFIRM study (NCT00099437) compared fulvestrant 500 mg with fulvestrant 250 mg (n=736; fulvestrant 500 mg: 56.6% with VM; fulvestrant 250 mg: 52.9% with VM); patients had received prior ET for adjuvant/advanced disease. The treatment effect of fulvestrant 500 mg vs comparator ET was determined using log-rank tests.

RESULTS

In FALCON, there was a greater treatment effect with fulvestrant 500 mg vs anastrozole for progression-free survival (PFS) in the non-VM group (hazard ratio [HR] 0.59) vs the VM group (HR 0.99). A consistent treatment effect was observed for fulvestrant 500 mg vs comparator for PFS in FIRST (non-VM HR 0.58; VM HR 0.82) and CONFIRM (non-VM HR 0.72; VM HR 0.86). Median PFS of fulvestrant 500 mg vs comparator in non-VM and VM subgroups was: 22.3 months (m) vs 13.8 m and 13.8 m vs 15.9 m, respectively, in FALCON; 34.0 m vs 21.3 m and 9.8 m vs 9.9 m in FIRST; and 10.4 m vs 5.9 m and 4.7 m vs 4.0 m in CONFIRM.

Clinical benefit rate with fulvestrant 500 mg vs anastrozole in FALCON was 87.4% vs 75.2% in the non-VM group, and 71.9% vs 73.1% in the VM group.

Overall survival (OS) in FALCON (31% maturity) showed a greater treatment effect with fulvestrant 500 mg vs anastrozole in the non-VM group vs the VM group (HR 0.60 vs 1.09). In terms of OS, in FIRST there was a greater treatment effect with fulvestrant 500 mg vs anastrozole in the non-VM group compared with the VM group (HR 0.68 vs 0.86). In CONFIRM, improved OS was observed with fulvestrant 500 mg vs fulvestrant 250 mg; this treatment effect was consistent in non-VM (HR 0.78) and VM subgroups (HR 0.83).

CONCLUSIONS

In three studies, an improved treatment effect of fulvestrant 500 mg vs comparator ET for HR+ LA/MBC was observed in patients with non-VM. The treatment effect of fulvestrant 500 mg vs comparator for PFS across all three studies appeared consistent. A reduced treatment effect of fulvestrant 500 mg vs comparator was generally seen in patients with VM, although fulvestrant 500 mg was still as effective as, or slightly more effective than, the comparator. These data suggest that patients without VM may benefit more from fulvestrant 500 mg than patients with VM.

Citation Format: Roberston JFR, Di Leo A, Fazal M, Lichfield J, Ellis MJ. Fulvestrant for hormone receptor-positive advanced breast cancer in patients with visceral vs non-visceral metastases: Findings from FALCON, FIRST, and CONFIRM [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 PD5-09.

Abstract P6-14-01: The effect trial: A randomized phase II trial evaluating two different doses of weekly (W) NAB-paclitaxel (NP) as first-line chemotherapy in older breast cancer (BC) patients (pts)

Background: W taxanes (T) are commonly used in the treatment of older BC pts, with neurotoxicity (NTX) and fatigue being dose-limiting toxicities with a possible negative impact on function. No prospective data exists on the safety and efficacy of W NP in this population. NP might be of particular value in older pts, due to no need for premedication with steroids and shorter time to recovery from neurotoxicity than conventional T, resulting in a reduced risk of exacerbation of comorbidities such as hypertension and diabetes, and possibly of functional decline (FD). Methods: Pts aged ≥ 65 years (y) with Her-2 negative or Her-2 positive (+), but contraindicated to anti-Her-2 therapy, advanced BC were randomized to receive NP as first-line chemotherapy at either 100 (Arm A) or 125 mg/m2 (Arm B), days 1, 8, 15 q 28. The primary end-point was event-free survival (EFS). An event was either disease progression (PD), death, or FD - defined as a decrease of at least 1 point from baseline values of activities of daily living (ADL) or instrumental ADL (IADL), deemed by the investigator as treatment-related and confirmed at the subsequent cycle. Secondary endpoints included progression-free survival (PFS), response rate (RR) in pts with measurable disease, and incidence of adverse events (AEs). Results: From January 2013 to September 2016, 160 pts were randomized in 15 Italian centres; all but 2 who never started NP were eligible for final analysis. Pts median age was 72y (range 65-84) in Arm A and 73y (range 65-88) in Arm B. Median ECOG performance status was 0 (range 0-2). Baseline IADL impairment was reported in 20 pts (25%) in both arms. &gt;80% pts had ER+ tumors; 2 pts had HER2+ disease. Visceral disease was present in 71% (Arm A) and 70% (Arm B) of pts. Prior exposure to T in the neo/adjuvant setting was 14% (Arm A) and 13% (Arm B). Median number of delivered cycles of NP was 6 (range 1-28 in Arm A, and 1-22 in Arm B), with 3 pts still on treatment. Dose reductions were similarly reported (72% of pts Arm A, 78% of pts Arm B). At a median follow-up of 21 months (mos) (Interquartile range 14-28.4) 140 events were observed. Arm A/Arm B: PD n=53(67%)/n=52(66%); FD n=13(15%)/n=14(18%), death n=3(4%)n=5(6%). Outcomes data are reported in the following table:

Outcomes Arm AArm BMedian EFS, mos (90% CI)6.2 (5.5-8.4)6.4 (5.8-7.7)Median PFS, mos (95% CI)8.3 (5.9-10.5)8.8 (7.4-10.3)RR (95% CI)37% (25-50)42% (30-54)

Fatigue (Arm A: grade (G)2 29%, G3 11%; Arm B: G2 46%, G3 5%) and NTX (Arm A: G2 15%, G3 4%; Arm B: G2 28%, G3 8%) were the most frequently reported AEs. No G4 AEs were reported with the exception of neutropenia (1 pt in arm A) and leucopenia (3 pts in Arm A, 1 pt in arm B). 1 G5 (sepsis) was recorded in Arm B. NTX was reported as the reason for treatment discontinuation in 21 pts (13%) of whom 16 (21%) in arm B. Conclusion: Looking at classical study endpoints (PFS, RR), both doses of NP are active in older pts. However, 17% of pts had to stop treatment due to FD, assessed according to predefined criteria. Due to similar efficacy and reduced NTX, W NP 100 is the suggested dose to be used in older pts with advanced BC.

Citation Format: Biganzoli L, Berardi R, Pedersini R, Minisini AM, Caremoli ER, Spazzapan S, Lima JS, Baldari D, Orlando L, Magnolfi E, Pistelli M, Brunello A, Zafarana E, Bernardo A, Leo S, Colleoni M, Donati S, De Placido S, Parolin V, Vitale S, Di Leo A, Puglisi F, Boni L, Cinieri S. The effect trial: A randomized phase II trial evaluating two different doses of weekly (W) NAB-paclitaxel (NP) as first-line chemotherapy in older breast cancer (BC) patients (pts) [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 P6-14-01.

Abstract GS5-02: Axillary dissection vs. no axillary dissection in patients with cT1-T2cN0M0 breast cancer and only micrometastases in the sentinel node(s): Ten-year results of the IBCSG 23-01 trial

BACKGROUND: The phase III IBCSG 23-01 multicenter, randomized, non-inferiority trial compared disease-free survival (DFS) in breast cancer patients with one or more micrometastatic (≤2 mm) sentinel nodes (SNs) randomized to either axillary dissection (AD) or no axillary dissection (no-AD). Results after 5 years showed no difference in DFS between the arms. Here we report results after a median follow-up of 9.8 years.

METHODS: Eligible patients had cancers of pathological diameter ≤5 cm and one or more micrometastatic (≤2 mm) foci, including isolated tumor cells, in the SNs. Patients with axillary macrometastases were excluded. Breast surgery was conservative or mastectomy. Eligible patients were randomized to AD vs. no-AD. The primary endpoint was disease-free survival (DFS); secondary endpoints were overall survival (OS), site of recurrence (particularly axillary recurrence), and surgical complications of AD. DFS and OS were estimated using the product-limit method, and the log-rank test was used to compare the treatment groups. Patients without a DFS or OS event were censored at the date of last follow-up. Non-inferiority margin for no-AD vs. AD was defined as a DFS hazard ratio (HR, no-AD relative to AD) of &lt;1.25, and was assessed using a z-test applied to the log HR. Active follow-up of patients was terminated in February 2017.

RESULTS: From 2001 to 2010, 934 patients were randomized at 27 centers; 931 were evaluable (467 in the no-AD group and 464 in the AD group). Median follow-up was 9.8 (IQR: 7.8–12.7) years. The number and types of first DFS events according to treatment group are shown in the Table.

Disease-free Survival EventsNo-ADADTotal101117Breast cancer related events7475Local1413Contralateral breast1012Regional [ipsilateral axillary events]9 [8]3 [2]Distant4147Non-breast cancer related events2742Second malignancies1723Death without prior cancer event62Death with unknown cancer status417

10-year DFS was 75% (95% confidence interval [CI]: 72%–81%) in the no-AD group and 75% (95% CI: 71%–79%) in the AD group (HR [no-AD vs. AD]=0.85; 95% CI: 0.65–1.11; log-rank p=0.23; non-inferiority p=0.002). There were 45 deaths in the no-AD group and 58 in the AD group. 10-year OS was 91% (95% CI: 88%–94%) in the no-AD group and 88% (95% CI: 85%–92%) in the AD group (HR [no-AD vs. AD]=0.77; 95% CI: 0.56–1.07; log-rank p=0.19).

CONCLUSION: Findings after a median follow-up of 9.8 years fully support the findings at 5 years in that no-AD is not inferior to AD with respect to DFS, and there is no significant difference between the arms for DFS and OS, thus confirming that AD is not indicated in patients with micrometastatic SNs.

Citation Format: Galimberti V, Cole BF, Viale G, Veronesi P, Vicini E, Intra M, Mazzarol G, Massarut S, Zgajnar J, Taffurelli M, Littlejohn D, Egli T, Tondini C, Di Leo A, Colleoni M, Regan MM, Coates AS, Gelber RD, Goldhirsch A. Axillary dissection vs. no axillary dissection in patients with cT1-T2cN0M0 breast cancer and only micrometastases in the sentinel node(s): Ten-year results of the IBCSG 23-01 trial [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 GS5-02.

A different perspective on sofosbuvir-ledipasvir treatment of patients with HCV genotype 1b cirrhosis: The ital-c network study

The effectiveness of a 12-week course of sofosbuvir-ledipasvir in treatment-experienced HCV genotype 1b-infected patients with cirrhosis is still under debate. Our primary endpoint was to compare the sustained virological response at post-treatment week 12 (SVR12) of sofosbuvir-ledipasvir in combination with ribavirin for 12 weeks, and sofosbuvir-ledipasvir alone for 24 weeks. This was a prospective observational study that enrolled 424 (195 naive, 229 experienced; 164 treated for 12 weeks with Ribavirin and 260 with sofosbuvir-ledipasvir alone for 24 weeks) consecutive HCV genotype 1b-infected patients with cirrhosis. The SVR12 rates were 93.9% and 99.2% in patients treated for 12 and 24 weeks, respectively (P = .002). The baseline characteristics of patients treated for 12 weeks were significantly different from those treated for 24 weeks as regards their younger age (P = .002), prevalence of Child-Pugh class A (P = .002), lower MELD scores (P = .001) and smaller number of nonresponders (P = .04). The shorter treatment was significantly associated with a lower SVR12 in univariate and multivariate analyses (P = .007 and P = .008, respectively). The SVR rate was unaffected by age, gender, BMI, Child-Pugh class, MELD score or previous antiviral treatment. Patients receiving ribavirin experienced more episodes of ascites and headache but less recurrence of hepatocellular carcinoma (HCC), and were prescribed more diuretics and cardiopulmonary drugs. No patient discontinued treatment. The therapeutic regimen of sofosbuvir-ledipasvir plus ribavirin administered for 12 weeks was less effective than sofosbuvir-ledipasvir alone given for 24 weeks. At odds with European guidelines, the recommended 12-week treatment with sofosbuvir-ledipasvir alone might be suboptimal for this setting of patients.

Systematic review with meta-analysis: post-operative complications and mortality risk in liver transplant candidates with obesity

BACKGROUND

International guidelines rate class III (morbid) obesity (body mass index [BMI]≥40 kg/m² ) as a relative contraindication for liver transplantation (LT) requiring further research. Moreover, data on the mortality risk in candidates with a BMI: 30-34.9 and 35-39.9 kg/m² (class I and class II obesity, respectively) are weak.

AIM

To compare post-operative complications and mortality risks in all obese candidates vs candidates with a BMI: 18.5-29.9 (normal/overweight) assumed as controls.

METHODS

We searched the Cochrane library, PubMed, Scopus, Web-of-Science and article reference lists, restricted to the English language, and selected cohort studies analysing the following outcomes: all-causes mortality (at 30 days, 1-2-3-5 years), post-operative and cardiopulmonary complications, hospital and intensive care unit (ICU) length of stay. Two reviewers independently extracted the studies data and a third one resolved discrepancies.

RESULTS

Twenty-four studies comprising 132 162 patients met the inclusion criteria. As compared to controls, mortality risk was increased at all time-periods (except at 3 years) for a BMI≥40, at 30 days for a BMI: 30-34.9 and in none of the considered time-periods for a BMI: 35-39.9. Post-operative complications were significantly higher for a BMI>30 and 30-34.9. Due to the shortage/absence of data, we evaluated cardiopulmonary complications, hospital and ICU length of stay only in the BMI≥30 category. In these patients, only cardiopulmonary complications were increased as compared to controls.

CONCLUSIONS

Morbid obesity has an impact on patients' survival after LT. However, since even a BMI>30 increases post-transplant complications, new strategies should be included in the LT programme to favour weight loss in all obese candidates.

De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017

The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their intensity, duration and side-effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment of many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high-risk patients, while encouraging omission of boost in low-risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemotherapy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care in both the developed and developing world.

Small intestinal bacterial overgrowth and celiac disease: A systematic review with pooled-data analysis

BACKGROUND

A link between small intestinal bacterial overgrowth (SIBO) and celiac disease (CD) has been hypothesized.

METHODS

Literature search was performed in main medical databases. Methods of analysis/inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations. The end-point was to estimate, by a pooled-data analysis, SIBO prevalence in CD. Proportions/percentages and their 95% confidence intervals (CI) were calculated by inverse variance method, whereas odd ratios (OR) and their 95% CI were estimated, where available, based on the Mantel-Haenszel method. Data were entered into the RevMan 5.3 software.

KEY RESULTS

Eleven articles fulfilled considered criteria. The pooled mean prevalence of SIBO in CD was 20% (95% CI of 10%-30%). In comparison to asymptomatic controls, CD was associated to higher risk of SIBO, with an OR of 10.52 (95% CI 2.69-41.21, P=.0007). Jejunal aspirate culture assessed SIBO prevalence of 11% (95% CI 3%-19%) in CD, whereas breath tests detected a higher value (23%, 95% CI 10%-37%). The pooled prevalence of SIBO in CD patients who were symptomatic despite a GFD was 28% (95% CI 10%-47%), higher than in asymptomatic celiac patients (pooled prevalence of 10%, with a 95% CI of 3%-16%), despite not statistically significant (P=.06). When GFD-unresponsive CD was defined only by clinical persistence of symptoms, the prevalence of SIBO was higher than in the case of villous atrophy association (31% vs 16% P=.33).

CONCLUSIONS

The heterogeneity of available studies may not support a relationship SIBO-CD. Nevertheless, SIBO could be more common in CD when symptoms do not improve after GFD.

Toxicity profile differences of adjuvant docetaxel/cyclophosphamide (TC) between Asian and Caucasian breast cancer patients

AIM

For early-stage breast cancer, four cycles of docetaxel and cyclophosphamide (TC) was proven superior to doxorubicin plus cyclophosphamide in the US Oncology 9375 trial. Given primary prophylactic antibiotics, 5% febrile neutropenia was recorded in a population comprising 75.5% Caucasians. Smaller trials and retrospective studies reviewing TC use in Asian patients did not produce similar incidence rates. This study aims to discover the variable hematological toxicities with TC use in Caucasian and Asian patients.

METHODS

Breast cancer data was retrospectively reviewed for patients receiving adjuvant docetaxel 60-75 mg/m² plus cyclophosphamide 600 mg/m² from six countries (China, Hong Kong, Japan, Taiwan, Italy, and United States). Similar number of patients with relatively balanced baseline characteristics were chosen for analysis of hematological and nonhematological toxicities and survival data.

RESULTS

From March 2004 to July 2013, data of 227 patients (127 Asians and 100 Caucasian) patients were analyzed for treatment-related toxicities. During the four cycles of TC, Asians had a significantly higher rate of grade ≥2 neutropenia than Caucasians (45.7% vs 6.0%; P <0.001) and significantly more grade ≥3 neutropenia events were documented (respectively 30.7% vs 4.0%, P <0.001). The prophylactic use of G-CSF was similar; 26.0% in Asians and 28.0% in Caucasian (P = 0.764). There were no differences in nonhematological toxicities. No significant difference in disease-free survival was observed between Asians and Caucasians (log-rank P = 0.910).

CONCLUSIONS

Ethnic differences in toxicity profile exist between Asian and Caucasian patients given adjuvant TC. Over 30% Asians but less than 5% Caucasians experienced grade ≥3 neutropenia.

Abstract P6-02-07: Metabolomic analysis by nuclear magnetic resonance spectroscopy discriminates hormone receptor positive/HER2 negative breast cancer cell lines resistant to palbociclib

Introduction: Clinical trials of palbociclib in combination with endocrine therapy have recently shown unprecedented activity for the treatment of hormone receptor positive/HER2 negative (HR+/HER2neg) advanced breast cancer. However, de novo and acquired resistance to palbociclib limit its clinical utility. Moreover, combining palbociclib with endocrine therapy increases toxicity and costs of the treatment. Identifying patients more likely to benefit from this compound and understanding the mechanisms of resistance to palbociclib is critical. In this study we investigated whether metabolomic profiles of breast cancer cell lines with acquired resistance to palbociclib (PDR) differ from their sensitive counterpart (PDS). In addition we sought to identify metabolic biomarkers of sensitivity to palbociclib by analyzing a breast cancer cell line unable to acquire resistance to palbociclib.

Material and methods: We have established in our lab three PDR HR+/HER2neg breast cancer models (MCF7L, T47D and ZR75-1) by chronically exposing cells to escalating doses of palbociclib. PDR derivatives show IC50 values 6 to 30 times higher than their PDS counterparts. One additional model, CAMA-1, was unable to develop resistance. Whole-cell lysates and conditioned cell culture media from five replicates of each of the PDS and PDR models and from CAMA-1 were analyzed by nuclear magnetic resonance (NMR). Principal component analysis (PCA) was used as first exploratory analysis and as dimension reduction technique. Canonical Analysis (CA) was used to discriminate different groups. Differentially expressed metabolites between PDR and PDS models and between CAMA-1 and PDS cells were analyzed.

Results: Unsupervised PCA analyses of H NMR spectra, in which no information about PDS and PDR was inserted in the statistical model, correctly identified individual cell lines on both whole-cell lysates and conditioned media. However this analysis did not discriminate PDS from PDR within each model. Using a supervised approach, in which the statistical model was trained to discriminate between PDS and PDR, these groups were categorized with accuracy of 80% using whole-cell lysates and of 65% using conditioned media, using a cross-validation analysis by repeatedly testing the model on blind samples. CAMA-1 was correctly identified as a PDS model; however it showed a distinct metabolic profile compared to other PDS models. Over 30 metabolites were identified as differentially expressed between PDS and PDR models in lysates and conditioned media, but only glycerophosphocholine levels in conditioned media remained significantly higher in PDR compared to PDS models after correction for multiple testing.

Conclusions: In this study we show that analysis of metabolic profile of cells lysates discriminates PDR from PDS cell lines with a high accuracy. Analysis of metabolic pathways implicated in resistance/sensitivity to palbociclib is ongoing and might help identifying new targets to overcome resistance. Additionally, metabolites associated with palbociclib resistance may be potentially tested in clinical samples as biomarkers for patients stratification. Further studies are warranted.

Citation Format: Bonechi M, Guarducci C, Meoni G, Tenori L, Biagioni C, Schiff R, Osborne CK, Luchinat C, Di Leo A, Malorni L, Migliaccio I. Metabolomic analysis by nuclear magnetic resonance spectroscopy discriminates hormone receptor positive/HER2 negative breast cancer cell lines resistant to palbociclib [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 P6-02-07.

Abstract PD4-06: Investigation of the recurrence dynamics of breast cancer (BC) according to the body mass index (BMI)

Background:

In cancer follow-up (FU), in addition to the evaluation of disease free and overall survival probabilities, there is a fundamental need of assessing the recurrence dynamics. In BC as well as in other cancers, the hazard function for first recurrence presents multiple peaks, with a first major peak occurring before three years of FU. Although the baseline risk is modulated by known prognostic factors with possible time dependent effects such as the estrogen receptor (ER), so far no other factor proved to disentangle this multi-peak behavior. Here, we postulated that adiposity, which is closely related to a state of hyperinsulinemia and chronic inflammation, and reflected by increased patient's BMI, could influence the recurrence dynamics.

Material and methods:

In this study 777 patients with early node-positive BC from a phase III randomized clinical trial were considered (Piccart et al. JCO 2001). The trial compared intermediate or full doses of epirubicin–cyclophosphamide with cyclophosphamide, methotrexate and 5-fluorouracil. BMI was calculated using the WHO classification and was available for 734 patients, of whom 27(4%) were underweight, 377(51%) normal, 213(29%) overweight and 117(16%) obese. Underweight and normal patients were grouped together. Disease free survival (DFS), loco-regional and distant recurrence endpoints were considered. Median FU-time was 15.4 years. Cox regression analysis was performed, adjusting for standard clinico-pathological variables and treatment. Piecewise exponential models with cubic natural and regularized tensor product splines were carried out to estimate the hazard function according to categorical and continuous BMI, respectively.

Results:

Older age at diagnosis, postmenopausal status, and increased tumor size were significantly associated with increased BMI. Adjusted Cox models supported the association between overweight and disease recurrence (HR=1.39; 95%CI=1.05-1.84) as well as distant metastases (HR=1.41; 95%CI=1.01-1.97). There was no evidence of association for loco-regional recurrences.

We observed a multi-peak behavior of distant recurrences for all BMI categories. Although, there was no shift of the first peak of recurrences according to BMI categories, occurring at ∼2.5 years of FU, a major increase in peak heights for the overweight and obese patients was evident. Obese patients showed a sharper first peak. When considering the three BMI categories according to the ER-status, we observed the worst prognosis for overweight ER-negative patients, as well as different recurrence patterns (Table).

NormalOverweightObeseER-positiveMain recurrence peak culminating at 2 years, with multiple smaller peaks laterOne broad peak around 3 years and one smaller around 10 yearsOne narrow peak at 2 years and one smaller around 10 yearsER-negativeSimilar pattern to ER-positive BC, with however major increase in height of first peakOne broad peak around 3 years, with a major increase in height compared to ER-positive BCOne peak at 2-3 years

Conclusion:

This is the first study to show that both the ER-status of the tumor and the patient's BMI at diagnosis are influencing the recurrence dynamics related to BC dormancy.

Citation Format: Biganzoli E, Desmedt C, Fornili M, Three-arms Investigators, de Azambuja E, Di Leo A, Sotiriou C, Piccart M, Demicheli R. Investigation of the recurrence dynamics of breast cancer (BC) according to the body mass index (BMI) [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 PD4-06.