Abstract P6-03-05: Clinico-pathological co-variates define a predictive model of breast cancer related lymphoedema (BCRL) in patients undergoing axillary surgery for breast cancer

Clinico-pathological co-variates define a predictive model of breast cancer related lymphoedema (BCRL) in patients undergoing axillary surgery for breast cancer CC Tang1*, J Timbres2*, KWD Ramsey1, A Mera2, S Irshad2, E Sawyer2, AA Khan1 1 Department of Plastic Surgery, The Royal Marsden Hospital, London, UK 2 School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, Guy’s Cancer Centre, King’s College London, London, UK. *These authors contributed equally Introduction Breast cancer-related lymphoedema (BCRL) negatively impacts body image, limb function and quality-of-life during cancer survivorship and affects 20% of women undergoing axillary clearance (ALND).1 Stratifying women undergoing axillary intervention into high- and low-risk groups for BCRL is important to identify those most likely to benefit from surgical interventions for lymphoedema prevention (eg LYMPHA) and mitigate BCRL risk in this subset of patients. In this study, we aimed to identify prognostic factors for lymphoedema incidence to develop a more accurate model of BCRL risk. Methods We performed a retrospective cohort study of breast cancer patients undergoing axillary surgery with (Ly+) and without (Ly-) subsequent lymphoedema. Controls were identified from the Breast Cancer Clinical Database, Guy’s and St Thomas’ Hospital NHS Foundation Trust (GSTT)) and diagnosed between 2000-2016, while cases were identified from the Lymphoedema Clinic at GSTT, diagnosed between 2000-2020. A multivariate logistic regression model was derived from univariate analyses using a stepwise, iterative process, confirmed with lasso regression, and evaluated within training and validation datasets to define a predictive risk score using methods described by Pavlou et al.2 Results 2040 patients (Ly+=541, Ly-=1499) who underwent axillary surgery (ALND = 1171, SLNB = 755) (were included in our analysis with a median follow up of 7.2 years (Ly+) and 9.8 years (Ly-). The final predictive model of BCRL risk contained variables for: mastectomy, grade, T-stage, N-stage, ER status, chemotherapy and radiotherapy. Here, specifically radiotherapy including a supraclavicular fossa field was associated with developing lymphoedema. The Hosmer–Lemeshow goodness-of-fit test showed the model to be well calibrated, and evaluation of the risk score using ROC curves showed good discrimination (AUC: 0.795). Lymphoedema was not found to negatively affect overall (unadjusted HR: 1.19 (95% CI: 0.92-1.53); p=0.178 and adjusted HR: 0.53 (95% CI: 0.38-0.73); p< 0.001) or disease free (unadjusted HR: 2.03 (95% CI: 1.59-2.61); p< 0.001 and adjusted HR: 0.92 (95% CI: 0.68-1.23); p=0.57) survival. Conclusion Our study identified clinico-pathological factors such as mastectomy, grade, T-stage, N-stage, ER status, chemo- and radiotherapy (specifically radiotherapy including a supraclavicular fossa field) to be predictive of developing BCRL following axillary surgery. Our model requires further validation but may have utility in stratifying patients for whom surgical strategies for lymphoedema prevention could be deployed to mitigate BCRL risk. References 1. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013 May;14(6):500-15. doi: 10.1016/S1470-2045(13)70076-7. Epub 2013 Mar 27. PMID: 23540561. 2. Pavlou M, Ambler G, Seaman S R, Guttmann O, Elliott P, King M et al. How to develop a more accurate risk prediction model when there are few events BMJ 2015; 351 :h3868 doi:10.1136/bmj.h3868

Citation Format: Chee Chee Tang, Jasmine Timbres, Kelvin Ramsey, Anca Mera, Sheeba Irshad, Elinor Sawyer, Aadil Khan. Clinico-pathological co-variates define a predictive model of breast cancer related lymphoedema (BCRL) in patients undergoing axillary surgery for breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-03-05.

Cancer care for Ukrainian refugees: Strategic impact assessments in the early days of the conflict

BACKGROUND

The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts.

METHODS

By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees.

FINDINGS AND CONCLUSIONS

The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

The Impact of COVID-19 on the Delivery of Systemic Anti-Cancer Treatment at Guy's Cancer Centre

BACKGROUND

This study aimed to assess the outcome of cancer patients undergoing systemic anti-cancer treatment (SACT) at our centre to help inform future clinical decision-making around SACT during the COVID-19 pandemic.

METHODS

Patients receiving at least one episode of SACT for solid tumours at Guy's Cancer Centre between 1 March and 31 May 2020 and the same period in 2019 were included in the study. Data were collected on demographics, tumour type/stage, treatment type (chemotherapy, immunotherapy, biological-targeted) and SARS-CoV2 infection.

RESULTS

A total of 2120 patients received SACT in 2020, compared to 2449 in 2019 (13% decrease). From 2019 to 2020, there was an increase in stage IV disease (62% vs. 72%), decrease in chemotherapy (42% vs. 34%), increase in immunotherapy (6% vs. 10%), but similar rates of biologically targeted treatments (37% vs. 38%). There was a significant increase in 1st and 2nd line treatments in 2020 (68% vs. 81%; p < 0.0001) and reduction in 3rd and subsequent lines (26% vs. 15%; p = 0.004) compared to 2019. Of the 2020 cohort, 2% patients developed SARS-CoV2 infections.

CONCLUSIONS

These real-world data from a tertiary Cancer Centre suggest that despite the challenges faced due to the COVID-19 pandemic, SACT was able to be continued without any significant effects on the mortality of solid-tumour patients. There was a low rate (2%) of SARS-CoV-2 infection which is comparable to the 1.4%-point prevalence in our total cancer population.

Survival Outcomes in Invasive Lobular Carcinoma Compared to Oestrogen Receptor-Positive Invasive Ductal Carcinoma

Invasive lobular breast cancer (ILC) accounts for 10-15% of breast cancers and has distinct characteristics compared with the more common invasive ductal carcinoma (IDC). Studies have shown that ILC may be less sensitive to chemotherapy than IDC, with lower rates of complete pathological response after neo-adjuvant chemotherapy, but it is not clear how this affects long-term survival. Patients at Guy's and St Thomas' NHS Foundation Trust between 1975 and 2016 diagnosed with ER+ IDC or ER+ ILC were eligible for inclusion. Kaplan-Meier plots and Cox proportional-hazards regression models were used for analysis. There was no difference in overall survival comparing ER+ ILC to ER+ IDC (OR: 0.94, 95% CI: 0.83, 1.04) with a median follow-up time of 8.3 years compared to 8.4 years in IDC. However, ER+HER2- ILC had worse survival compared to ER+HER2- IDC in those that received chemotherapy (OR: 1.46, 95% CI: 1.06, 2.01). Here, median follow-up time was 7.0 years in ILC compared to 8.1 years in IDC. These results indicate worse overall survival after chemotherapy (neo-adjuvant and adjuvant) in ILC compared to ER+HER2- IDC even when correcting for tumour grade, age, size, and nodal involvement, but validation is needed in a larger study population.

Abstract PS8-06: Survival outcomes after chemotherapy in invasive lobular carcinoma compared to estrogen receptor positive invasive ductal carcinoma

Introduction

Invasive lobular breast cancer (ILC) accounts for 10-15% of all invasive breast carcinomas and has distinct clinical and biological characteristics compared with the more common invasive ductal carcinoma (IDC). They are generally ER-positive (ER+) with the exception of a small number of pleomorphic cases and there is some evidence that the 10-year survival rate of women with ILC is lower than that for ER+ IDC. Furthermore, studies have shown that ILC may be less sensitive to chemotherapy than IDC, with lower rates of complete pathological response after neoadjuvant chemotherapy, but it is not clear what effects this has on long term survival. The aim of this study was to investigate whether ER+ ILC patients who received chemotherapy (neoadjuvant or adjuvant) had similar outcomes to ER+ IDC patients who received chemotherapy.

Methods

Patients were diagnosed at Guy’s & St Thomas’ NHS Foundation Trust between 1971 and 2016 and were eligible for inclusion into the study if they were female, had been diagnosed with either IDC or ILC, if their tumours were ER+, and if they received chemotherapy. They were followed up from date of primary diagnosis until 30th June 2019 and were assumed to be alive in the absence of a reported death date. Patients with estrogen receptor negative (ER-) tumours were excluded, due to well-known chemosensitivity in these breast cancer subtypes. Data used was requested from the Guy’s & St Thomas’ Breast Cancer Database.

Results

Of 5526 patients diagnosed with ILC or IDC between 1971 and 2016, 3945 were ER+ with 3436 IDC and 509 ILC. ER+ IDC and ILC had similar survival for the first 10 years after diagnosis after which outcomes began to diverge with worse outcomes in ILC. The 10-year and 15-year survival of 59.3% and 47.5% respectively were seen in IDC, and 58.6% and 44.6% in ILC. 1327 ER+ patients who received chemotherapy were selected for analysis, of which 161 (12.1%) were ILC and 1166 (87.9%) were IDC. 159 (12.0%) of patients received neo-adjuvant chemotherapy, while 1168 (88.0%) received adjuvant chemotherapy. In chemotherapy patients, 10-year survival was 53.1% in ILC and 54.0% in IDC, and by 15 years this was 35.1% and 44.7% respectively. In ER+ chemotherapy patients, there was no evidence of a crude association between histological subtype and survival (HR: 1.19, 95% CI: 0.97, 1.47) using Cox regression. However, the multivariate Cox regression model estimated a significantly worse outcome in ILC compared to IDC (HR: 1.28, 95% CI: 1.02, 1.60), adjusted for chemotherapy (neo-adjuvant or adjuvant), stage (I-IV), grade, HER2 status, time period of diagnosis, and surgery type (mastectomy or excision). When stratified by chemotherapy, this association was only observed in patients that received adjuvant treatment.

Conclusion

This study suggests that ER+ ILC patients who received adjuvant chemotherapy may have a worse outcome than ER+ IDC when adjusted for stage and grade. This is a potentially important finding but needs to be studied in a larger population treated with modern chemotherapy regimens. Other studies have shown that the outcome for ILC is better in the first 5 years after diagnosis compared to ER+ IDC but worsens after 10 years, as it does in this study. Thus, having long follow up is essential in order to be able to detect any differences in survival between ILC and ER+ IDC. Nonetheless, this study has displayed a significant difference in survival between ER+ ILC and ER+ IDC receiving adjuvant chemotherapy, and thus recommendations for adjuvant chemotherapy may need to be considered separately for the two subtypes. Furthermore, it would be beneficial to develop a tool that could help in identifying cases of ILC that would most benefit from chemotherapy.

Citation Format: Jasmine Timbres, Charlotte Moss, Anca Mera, Anna Haire, Cheryl Gillett, Mieke Van Hemelrijck, Elinor Sawyer. Survival outcomes after chemotherapy in invasive lobular carcinoma compared to estrogen receptor positive invasive ductal carcinoma [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS8-06.

Frequency of Pathogenic Germline Variants in CDH1, BRCA2, CHEK2, PALB2, BRCA1, and TP53 in Sporadic Lobular Breast Cancer

BACKGROUND

Invasive lobular breast cancer (ILC) accounts for approximately 15% of invasive breast carcinomas and is commonly associated with lobular carcinoma in situ (LCIS). Both have been shown to have higher familial risks than the more common ductal cancers. However, there are little data on the prevalence of the known high and moderate penetrance breast cancer predisposition genes in ILC. The aim of this study was to assess the frequency of germline variants in CDH1, BRCA2, BRCA1, CHEK2, PALB2, and TP53 in sporadic ILC and LCIS diagnosed in women ages ≤60 years.

METHODS

Access Array technology (Fluidigm) was used to amplify all exons of CDH1, BRCA2, BRCA1, TP53, CHEK2, and PALB2 using a custom-made targeted sequencing panel in 1,434 cases of ILC and 368 cases of pure LCIS together with 1,611 controls.

RESULTS

Case-control analysis revealed an excess of pathogenic variants in BRCA2, CHEK2, PALB2, and CDH1 in women with ILC. CHEK2 was the only gene that showed an association with pure LCIS [OR = 9.90; 95% confidence interval (CI), 3.42-28.66, P = 1.4 × 10^-5] with a larger effect size seen in LCIS compared with ILC (OR = 4.31; 95% CI, 1.61-11.58, P = 1.7 × 10^-3).

CONCLUSIONS

Eleven percent of patients with ILC ages ≤40 years carried germline variants in known breast cancer susceptibility genes.

IMPACT

Women with ILC ages ≤40 years should be offered genetic screening using a panel of genes that includes BRCA2, CHEK2, PALB2, and CDH1.

Invasive breast cancer over four decades reveals persisting poor metastatic outcomes in treatment resistant subgroup - the "ATRESS" phenomenon

BACKGROUND

Major advances in breast cancer treatment have led to a reducuction in mortality. However, there are still women who are not cured. We hypothesize there is a sub-group of women with treatment-resistant cancers causing early death.

METHODS

Between 1975 and 2006, 5392 women with invasive breast cancer underwent surgery at Guy's Hospital, London. Data on patient demographics, tumour characteristics, treatment regimens, local recurrence, secondary metastasis, and death were prospectively recorded. We considered four time periods (1975-1982, 1983-1990, 1991-1998, 1999-2006). Risks and time to event analysis were performed with Cox proportional hazards model and Kaplan-Meier estimation.

RESULTS

Unadjusted hazard ratios for developing metastasis and overall mortality relative to the 1975-1982 cohort decreased steadily to 0.23 and 0.63, respectively in 1999-2006. However, metastasis-free interval shortened, with the proportion of women developing metastasis ≤5 years increasing from 73.9% to 83.0%. Furthermore, median post-metastatic survival decreased from 1.49 years to 0.94 years. Applying our risk criteria identified the presence of ±200 patients in each cohort who developed metastasis early and died within a much shorter time frame.

CONCLUSIONS

Advances in treatment have decreased the risk of metastasis and improved survival in women with invasive breast cancer over the last 40 years. Despite this, a subpopulation with shorter metastasis-free and post-metastatic survival who are unresponsive to available treatment remains. This may be due to the ATRESS phenomenon (adjuvant therapy-related shortening of survival) secondary to preselection inherent in adjuvant therapy, successful treatment of less malignant tumour cells and treatment-induced resistance in the remaining tumour clones.

Estrogen receptor (ER) status and survival outcomes in HER2 positive (+) metastatic breast cancer (mBC)

e12503

Background: The oncological management of HER2+ mBC is complicated by the development of resistance to HER2-directed therapies (HER2-DTs). This project analyses real-world clinical data to determine disease response patterns that may guide treatment sequencing decisions. Methods: This collaborative project analysed HER2+ mBC datasets held by the Sussex Cancer Centre and Guy’s Cancer Centre, UK. The datasets were generated by reviewing clinical notes, radiology and e-prescribing records to collect clinical data on patients diagnosed with HER2+ mBC between 01/01/2013 – 30/09/2018. Results: 138 patients with a median age of 59 years (30 - 89 years) were diagnosed with HER2+ mBC during this time period: 88 were ER+ (63.7%) and 50 were ER- (36.3%); the median OS is 41.1 mos. (range 0.7 - 62 mos.). Patients with HER2+ mBC were more likely to present with visceral metastases (68.1%, n = 94). A poorer median OS was identified in patients with ER+ HER2+ mBC (35.5 mos.) vs ER- HER2+ mBC (MNR). A benefit to median OS was observed with first line treatment using Docetaxel/Trastuzumab/Pertuzumab (THP) compared to other HER2-DTs ((54.5 mos. (n = 76) vs 26.7 mos. (n = 40)) 65.2% (n = 90) were previously treated for early breast cancer (EBC), evenly distributed across the 2 groups ER+ (64.7%, n = 57) vs ER- (66%, n = 33). 53.7% (n = 50) received trastuzumab with neo-adjuvant/adjuvant therapy (NACT/ACT). Patients previously treated for EBC demonstrated a poorer median OS (34 mos.) when compared to patients with de-novo mBC (MNR). When treated for EBC, ER+ disease was less likely to have a pathological complete response (pCR) with NACT (ER+ 22.2% (n = 4/18) vs ER- 50% (n = 5/10)). PFS data in response to an array of prescribed systemic therapies will be presented. Conclusions: Though, HER2 signalling is considered the dominant signalling pathway in HER2+ breast cancer, pre-clinical research indicates that the ER pathway represents an important escape mechanism influencing the development of resistance. Lack of efficacy (pCR) to NACT in ER+HER2+ EBC may translate to poorer outcomes (OS) when these patients develop MBC. Earlier targeting of the ER pathway in conjunction with HER2-DTs may contribute to improving patient outcomes.

Frequency of pathogenic germline variants in BRCA1, BRCA2, PALB2, CHEK2 and TP53 in ductal carcinoma in situ diagnosed in women under the age of 50 years

INTRODUCTION

Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive ductal breast cancer, and approximately 20% of screen-detected tumours are pure DCIS. Most risk factors for breast cancer have similar associations with DCIS and IDC; however, there is limited data on the prevalence of the known high and moderate penetrance breast cancer predisposition genes in DCIS and which women with DCIS should be referred for genetic screening. The aim of this study was to assess the frequency of germline variants in BRCA2, BRCA1, CHEK2, PALB2 and TP53 in DCIS in women aged less than 50 years of age.

METHODS

After DNA extraction from the peripheral blood, Access Array technology (Fluidigm) was used to amplify all exons of these five known breast cancer predisposition genes using a custom made targeted sequencing panel in 655 cases of pure DCIS presenting in women under the age of 50 years together with 1611 controls.

RESULTS

Case-control analysis revealed an excess of pathogenic variants in BRCA2 (OR = 27.96, 95%CI 6.56-119.26, P = 2.0 × 10^-10) and CHEK2 (OR = 8.04, 95%CI 2.93-22.05, P = 9.0 × 10^-6), with weaker associations with PALB2 (P = 0.003), BRCA1 (P = 0.007) and TP53 (P = 0.02). For oestrogen receptor (ER)-positive DCIS the frequency of pathogenic variants was 9% under the age of 50 (14% with a family history of breast cancer) and 29% under the age of 40 (42% with a family history of breast cancer). For ER-negative DCIS, the frequency was 9% (16% with a family history of breast cancer) and 8% (11% with a family history of breast cancer) under the ages of 50 and 40, respectively.

CONCLUSIONS

This study has shown that breast tumourigenesis in women with pathogenic variants in BRCA2, CHEK2, PALB2, BRCA1 and TP53 can involve a DCIS precursor stage and that the focus of genetic testing in DCIS should be on women under the age of 40 with ER-positive DCIS.

A comparison of the left thoracoabdominal and Ivor-Lewis esophagectomy

The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor-Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749-1.1090) or time to recurrence (HR 0.973 95%CI 0.768-1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731-1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy.

Gene expression modules in primary breast cancers as risk factors for organotropic patterns of first metastatic spread: a case control study

BACKGROUND

Metastases from primary breast cancers can involve single or multiple organs at metastatic disease diagnosis. Molecular risk factors for particular patterns of metastastic spread in a clinical population are limited.

METHODS

A case-control design including 1357 primary breast cancers was used to study three distinct clinical patterns of metastasis, which occur within the first six months of metastatic disease: bone and visceral metasynchronous spread, bone-only, and visceral-only metastasis. Whole-genome expression profiles were obtained using whole genome (WG)-DASL assays from formalin-fixed paraffin-embedded (FFPE) samples. A systematic protocol was developed for handling FFPE samples together with stringent data quality controls to identify robust expression profiling data. A panel of published and novel gene sets were tested for association with these specific patterns of metastatic spread and odds ratios (ORs) were calculated.

RESULTS

Metasynchronous metastasis to bone and viscera was found in all intrinsic breast cancer subtypes, while immunohistochemically (IHC)-defined receptor status and specific IntClust subgroups were risk factors for visceral-only or bone-only first metastases. Among gene modules, those related to proliferation increased the risk of metasynchronous metastasis (OR (95% CI) = 2.3 (1.1-4.8)) and visceral-only first metastasis (OR (95% CI) = 2.5 (1.2-5.1)) but not bone-only metastasis (OR (95% CI) = 0.97 (0.56-1.7)). A 21-gene module (BV) was identified in estrogen-receptor-positive breast cancers with metasynchronous metastasis to bone and viscera (area under the curve = 0.77), and its expression increased the risk of bone and visceral metasynchronous spread in this population. BV was further orthogonally validated with NanoString nCounter in primary breast cancers, and was reproducible in their matched lymph nodes metastases and an external cohort.

CONCLUSION

This case-control study of WG-DASL global expression profiles from FFPE tumour samples, after careful quality control and RNA selection, revealed that gene modules in the primary tumour have differing risks for clinical patterns of metasynchronous first metastases. Moreover, a novel gene module was identified as a putative risk factor for metasynchronous bone and visceral first metastatic spread, with potential implications for disease monitoring and treatment planning.

Corticoids synergize with IL-1 in the induction of LCN2

OBJECTIVE

Lipocalin-2 (LCN2) is an adipokine that was first identified in neutrophil granules. In the last years it was recognized as a factor that could impair chondrocyte phenotype, cartilage homeostasis as well as growth plate development. Both pro-inflammatory cytokines and glucocorticoids (GCs) modulate LCN2 expression. Actually, GCs were found to be LCN2 inducers, suggesting that part of the negative actions exerted by these anti-inflammatory drugs at cartilage level could be mediated by this adipokine. So, in this study we wanted to investigate whether corticoids were able to act in synergy with IL-1 in the induction of LCN2 and the signaling pathway involved in this process.

MATERIALS AND METHODS

For the realization of this work, ATDC5 mouse chondrogenic cell line was used. We determined the mRNA and protein expression of LCN2 by real-time reverse transcription-polymerase chain reaction (RT-qPCR) and western blot respectively, after GC or mineralcorticoid treatment. Different signaling pathways inhibitors were also used.

RESULTS

GC and mineralcorticoid were able to induce the expression of LCN2 in ATDC5 cells. Interestingly, both corticoids synergized with IL-1 in the induction of LCN2. The effect of these corticoids on the expression of LCN2 occurred through GC or mineralcorticoid receptors and the kinases PI3K, ERK1/2 and JAK2.

CONCLUSIONS

Prolonged use of corticoids may have detrimental effects on cartilage homeostasis. Based on our results, we conclude that corticoids could increase the negative actions exerted by IL-1 by increasing the expression of LCN2.

Abstract P3-17-09: Resolution of DCIS in patients with early breast cancer receiving primary chemotherapy for invasive breast cancer

Background

Ductal Carcinoma in Situ (DCIS) plays a pivotal role in surgical planning for patients who are to undertake primary chemotherapy. As DCIS is not thought to be responsive to chemotherapy, many women with large primaries or extensive DCIS on initial diagnosis will be planned for and undergo mastectomy. To investigate the role of chemotherapy in invasive breast cancer with concomitant ductal carcinoma in situ (DCIS), we examined patients who had primary systemic therapy for a primary invasive cancer with either radiologically or histologically proven DCIS to see if there were patients in whom there was no evidence of DCIS at resection.

Methods

This was a retrospective single centre study. Examining the records of all patients who had received primary chemotherapy between January 2010 and October 2014.

Patients were identified through the Guy's breast cancer database and chemotherapy prescribing system. To fully assess the DCIS status, all patients were cross-referenced with the electronic notes on our electronic noting system (MOSAIQ), radiology on Patient Archiving and Communication System (PACS) and histology on our Electronic Patient Record (EPR).

Results

1526 patients were identified, of whom 156 underwent primary chemotherapy. Of these, 46 patients had a pre-chemotherapy biopsy confirming DCIS, of whom 30 also had radiological evidence of DCIS. A further 26 had micro-calcification on their initial imaging which was presumed to be DCIS.

Twelve of the 46 patients with biopsy proven DCIS at presentation did not have DCIS at resection. Of these 9 had a mastectomy, with 5 achieving a pathological complete response (pCR), of whom 4 had a complete radiological response (rCR).

Of the 26 who had micro-calcification pre-chemotherapy, 15 did not have DCIS in the resection specimen. Of these, 10 had a mastectomy, with 6 having a pCR of whom 3 also had rCR.

Conclusion

This retrospective study suggests that chemotherapy can influence DCIS, with 12 biopsy proven having a pCR post treatment. This may indicate that some patients may be spared mastectomy.

Although there were patients with radiological evidence of DCIS, without a confirmatory biopsy we cannot be sure that these were malignant. This highlights the need to ensure that all suspicious areas distant from the primary tumour should be biopsied before treatment.

In conclusion, for patients who have an excellent clinical and radiological response, even in the presence of DCIS at presentation, more intensive evaluation is indicated if conservative surgery is a possibility.

Citation Format: Chowdhury MHR, Thillai K, Lucey A, Michalarea V, Mera A, Karapanagiotou E, Sandri I, Mansi J. Resolution of DCIS in patients with early breast cancer receiving primary chemotherapy for invasive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-09.

Abstract P2-01-13: Can axillary lymph node clearance be avoided in women with node positive breast cancer receiving primary chemotherapy?

Background

For patients who receive primary chemotherapy for their early breast cancer the current practice for lymph node positive (LN) disease at presentation is in transition, with a drive towards sentinel LN biopsy (SLNB) rather than axillary node clearance (ANC) for patients who achieve a good response to primary chemotherapy. Boileau et al initially reported that approximately 30% of patients could potentially avoid clearance, but with a recommendation for further evaluation before including SLNB in guidelines for biopsy proven node-positive disease prior to primary chemotherapy for early breast cancer.

Methods

This was a retrospective single centre study. Examining the records of all patients who had received primary chemotherapy between January 2010 and October 2014.

Patients were identified through the Guy's Breast Cancer Database and chemotherapy prescribing system. To fully assess the LN status, all patients were cross-referenced with the electronic notes on our electronic noting system (MOSAIQ), radiology on Patient Archiving and Communication System (PACS) and histology on our Electronic Patient Record (EPR).

Results:

1526 patients were identified, of whom 156 underwent primary chemotherapy. 111 patients had suspicious nodes on imaging (ultrasound and/or MRI) and underwent LN biopsy. 69 patients had positive nodes pre-chemotherapy. 28 of these 69 patients (40.6%) had negative nodes at ANC, of these 14 (50%) had complete pathological complete response (pCR) in their primary tumour(s) of whom 12 (86%) had radiological CR prior to surgery. Of the 41 who remained positive only three achieved pCR of their primary tumour after chemotherapy.

22 patients were LN positive post primary chemotherapy, despite having been identified as initially LN negative. Of these 9 had a negative pre chemotherapy biopsy, and only 1 of these 22 patients had a pCR.

Discussion:

We have confirmed that ANC may be avoided in selected patients with LN involvement at presentation. In our series over 40% could have had SLNB instead. Factors supporting this approach include those patients who have an excellent radiological response to primary chemotherapy. Conversely, 22 of 87 (25%) had positive LN after chemotherapy having been initially thought to be LN negative at presentation, highlighting the possible need for multiple nodal sampling prior to chemotherapy as well as further nodal assessment after chemotherapy for complete staging.

Citation Format: Chowdhury MHR, Thillai K, Lucey A, Michalarea V, Mera A, Karapanagiotou E, Sandri I, Mansi J. Can axillary lymph node clearance be avoided in women with node positive breast cancer receiving primary chemotherapy? [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 P2-01-13.

Family history of breast cancer and its association with disease severity and mortality

A family history (FH) of breast cancer (BC) is known to increase an individual's risk of disease onset. However, its role in disease severity and mortality is less clear. We aimed to ascertain associations between FH of BC, severity and BC‐specific mortality in a hospital‐based cohort of 5354 women with prospective information on FH. We included women diagnosed at Guy's and St Thomas’ NHS Foundation Trust between 1975 and 2012 (n = 5354). BC severity was defined and categorized as good, moderate, and poor prognosis. Data on BC‐specific mortality was obtained from the National Cancer Registry and medical records. Associations between FH and disease severity or BC‐specific mortality were evaluated using proportional odds models and Cox proportional hazard regression models, respectively. Available data allowed adjustment for potential confounders (e.g., treatment, socioeconomic status, and ethnicity). FH of any degree was not associated with disease severity at time of diagnosis (adjusted proportional OR: 1.00 [95% CI: 0.85 to 1.17]), which remained true also after stratification by period of diagnosis. FH of BC was not associated with BC‐mortality HR: 0.99 (95% CI: 0.93 to 1.05). We did not find evidence to support an association between FH of BC and severity and BC‐specific mortality. Our results indicate that clinical management should not differ between women with and without FH, when the underlying mutation is unknown.

Progression of breast cancer following locoregional ipsilateral recurrence: importance of interval time

Background:

Studies comparing prognosis of breast cancer (BC) patients with and without locoregional recurrence (LR) present conflicting results. We aimed to improve our understanding of the impact of LR on prognosis by examining a large cohort of patients treated at Guy's and St Thomas' NHS Foundation Trust.

Methods:

Risk factors associated with BC-specific death were investigated using Cox proportional hazards regression in 5199 women diagnosed between 1975 and 2007. Breast cancer-specific death following LR was assessed with Poisson regression.

Results:

Overall, 552 women (11%) developed LR, with a median follow-up time of 4.28 years. Known factors associated with BC-specific death (tumour stage, grade, and nodal status) were of significance in our data. Women with a shorter disease-free interval had a worse prognosis. For instance, the HR for BC-specific death among women undergoing mastectomy with an LR 0.5–1 year after diagnosis of their primary tumour was 6.67 (95% CI: 3.71–11.99), when compared with women who did not experience LR.

Conclusions:

It often remains difficult to distinguish between a genuine LR and a new primary. The HRs for risk of BC-specific death following a second lesion suggest that they may act as a marker of systemic disease, large tumour burden, or depleted host defence. The clinically highly relevant impairment in prognosis calls for further research into the underlying mechanisms. We showed that for at least 15 years of follow-up, the prognosis in women following the occurrence of an LR may benefit from careful diagnostic and therapeutic management.

Age at diagnosis and distant metastasis in breast cancer--a surprising inverse relationship

INTRODUCTION

Predictors for site of distant metastasis and impact on survival in breast cancer are incompletely understood.

METHODS

Clinico-pathological risk factors for site of distant metastasis and survival were analysed in patients with invasive breast cancer treated between 1986 and 2006.

RESULTS

Of 3553 patients, with median follow-up 6.32years, 825 (23%) developed distant metastasis. The site of metastasis was bone in 196/825 (24%), viscera in 540/825 (65%) and unknown in 89 (11%). Larger primary invasive tumour size, higher tumour grade and axillary nodal positivity increased risk of metastasis to all sites. Lobular carcinoma was more likely to first metastasise to bone compared to invasive ductal carcinoma (NST). Oestrogen receptor (ER) negative, progesterone receptor (PgR) negative and/or Human epidermal growth factor (HER2) positive tumours were more likely to metastasise to viscera. A striking relationship between increasing age at diagnosis and a reduction in risk of distant metastasis to bone and viscera was observed. Median time to death from onset of metastatic disease was 1.52 (Interquartile range (IQR) 0.7-2.9)years for patients with bone metastasis and 0.7 (IQR 0.2-1.5)years for visceral metastasis. On multivariate analysis, despite the decrease in risk of distant metastasis with increasing age, there was an elevated hazard for death in patients >50years at diagnosis of metastasis if they developed bone metastasis, with a similar trend observed in the >70years age group if they developed visceral metastasis.

CONCLUSION

These findings indicate that there are biological mechanisms underlying the impact of age on the development of distant metastasis and subsequent death. This may have important implications in the treatment of breast cancer.

Integrated genomic analysis of triple-negative breast cancers reveals novel microRNAs associated with clinical and molecular phenotypes and sheds light on the pathways they control

Background

This study focuses on the analysis of miRNAs expression data in a cohort of 181 well characterised breast cancer samples composed primarily of triple-negative (ER/PR/HER2-negative) tumours with associated genome-wide DNA and mRNA data, extensive patient follow-up and pathological information.

Results

We identified 7 miRNAs associated with prognosis in the triple-negative tumours and an additional 7 when the analysis was extended to the set of all ER-negative cases. miRNAs linked to an unfavourable prognosis were associated with a broad spectrum of motility mechanisms involved in the invasion of stromal tissues, such as cell-adhesion, growth factor-mediated signalling pathways, interaction with the extracellular matrix and cytoskeleton remodelling. When we compared different intrinsic molecular subtypes we found 46 miRNAs that were specifically expressed in one or more intrinsic subtypes. Integrated genomic analyses indicated these miRNAs to be influenced by DNA genomic aberrations and to have an overall influence on the expression levels of their predicted targets. Among others, our analyses highlighted the role of miR-17-92 and miR-106b-25, two polycistronic miRNA clusters with known oncogenic functions. We showed that their basal-like subtype specific up-regulation is influenced by increased DNA copy number and contributes to the transcriptional phenotype as well as the activation of oncogenic pathways in basal-like tumours.

Conclusions

This study analyses previously unreported miRNA, mRNA and DNA data and integrates these with pathological and clinical information, from a well-annotated cohort of breast cancers enriched for triple-negative subtypes. It provides a conceptual framework, as well as integrative methods and system-level results and contributes to elucidate the role of miRNAs as biomarkers and modulators of oncogenic processes in these types of tumours.

Comparison of basal-like triple-negative breast cancer defined by morphology, immunohistochemistry and transcriptional profiles

Basal-like invasive breast cancer is an important clinical group because of its association with a triple-negative phenotype defined by the lack of expression of estrogen, progesterone and human epidermal growth factor receptors 2, relative lack of therapeutic options and poor prognosis. However, depending on the method used to define these lesions, morphological assessment, immunohistochemical markers or gene expression, a different set of tumors is captured. The aim of this study was to investigate the consequences of using different methodological approaches to define basal-like lesions among triple-negative breast carcinomas with regard to their clinicopathological features and patient outcome. The cohort consisted of 142 invasive breast cancers with a triple-negative receptor status. First, each was reviewed histologically and those with morphological basal-like features were characterized as 'Path-Basal'. Second, the 'Core Basal' immunohistochemical lesions, defined as cytokeratin 5/6 and/or epidermal growth factor receptor 1 positive, within the triple-negative breast cancers were identified, and third their classification based on gene expression profiling was retrieved and those in the molecular 'PAM50 basal-like' subtype recorded. A total of 116 basal-like breast cancers were identified among the 142 triple-negative breast cancers by at least one of these three classifications (80%), but only 13 samples were defined as basal-like with all three methods. None of these 13 tumors were associated with lymphovascular invasion. The 34 morphological 'Path-Basal' lesions were significantly associated with a lack of nodal metastases. Comparing the estimates of death in the three classifications, the highest risk of death was seen for the 'Core Basal' group. In this study, we highlight that the definition of basal-like breast cancer based on different methodologies varies significantly and does not identify the same lesions. This incomplete overlap of cases emphasizes the need for consistent or new approaches to improve precise identification.

[Brachial plexitis and myelitis and herpes-zoster lumbar plexus disorder in patient treated with infliximab]

Infliximab, a chimeric monoclonal antibody, is a TNF-a inhibitor approved for use in refractory rheumatoid arthritis and Crohn s disease. We present the case of a patient affected by severe rheumatoid arthritis who was successfully treated with infliximab. She suffered diverse neurological complications: brachial plexitis, asymptomatic thoracic myelitis with extensive lesions in MRI study, and herpes zoster lumbar plexitis. We review the neurological adverse effects of infliximab (aseptic meningitis, opportunistic germs infections, disseminated herpes zoster) and focus in their potential adverse effect to induce central and peripheral nervous system demyelination.

Effect of the first infliximab infusion on sleep and alertness in patients with active rheumatoid arthritis

OBJECTIVE

To assess the benefit of the first infliximab infusion on sleep disturbances in patients with RA Material and methods: Evaluation of RA activity, sleepiness (Epworth scale and multiple sleep latency test), alertness (steer clear test), and sleep structure (polysomnography) were conducted before and after the first infusion of infliximab in six female patients with RA.

RESULTS

The day after the first infliximab infusion, the mean (SD) number of tender (20 (2.4)) or swollen (15.3 (2)) joints and the morning stiffness (140 (61.9) min) had not changed. There were significant improvements in the median number of total sleep stage transitions per hour (median (IR) before v after infusion: 20.5 (43) v 7.5 (6); Wilcoxon paired test, p = 0.014), median percentage of phase I+II (83.5 (8) v 54.5 (24); p = 0.023), percentage of REM stages (2 (10) v 11.5 (8); p = 0.014), median percentage sleep efficiency (44 (22) v 75 (18); p = 0.014), median sleep latency (77.5 (150) v 25.5 (23) min; p = 0.023), and median number of hits in the steer clear test (48.5 (86) v 6 (45); p = 0.023). Neither objective nor subjective daytime sleepiness was noted. One obese patient had obstructive sleep apnoea syndrome.

CONCLUSIONS

Sleep and the alertness disturbances in RA improve with infliximab treatment. Improvement appears unrelated to joint discomfort amelioration but suggests a central effect through inhibition of circulating TNFalpha levels.

Organization of the chemokine genes in the human and mouse major clusters of CC and CXC chemokines: diversification between the two species

Chemokines are a family of small cytokines that play essential roles in the directed migration of various types of leukocytes. Based on the arrangement of the conserved cysteine residues, they are classified into two major subfamilies, CXC and CC, and two minor subfamilies, C and CX3C. So far, more than 40 members of this family have been identified in humans. Strikingly, the majority of CXC chemokine genes and that of CC chemokine genes are closely clustered at chromosomes 4q12-21 and 17q11.2, respectively. Similarly, the mouse major CXC and CC chemokine gene clusters are located on chromosomes 5 and 11, respectively. In order to understand the evolutionary processes that generated large numbers of CXC and CC chemokine genes in the respective chromosomal sites, we have constructed BAC and YAC contigs covering the human and mouse major clusters of CXC and CC chemokine genes. The results reveal that the organizations of CXC and CC chemokine genes in the major clusters are quite diverged between the two species most probably due to very recent gene duplications and rearrangements. Our results provide an important insight into the evolutionary processes that generated the major chemokine gene clusters and also valuable information in assigning the orthologues between human and mouse major cluster chemokines.

Immunochemical and enzymatic study of ceruloplasmin in rheumatoid arthritis

Forty adult patients (30 women and 10 men) with rheumatoid arthritis (RA), treated with nonsteroidal anti-inflammatory drugs, were studied. Serum levels of immunoreactive ceruloplasmin, oxidase activity of the ceruloplasmin and total copper, as well as the specific oxidase activity (enzyme activity per unit of mass) and the copper/immunoreactive ceruloplasmin relationship were significantly higher in the group of patients than in the healthy control group (p < 0.001). However, no significant difference was found for the concentration of non-ceruloplasmin copper between both groups. A statistically significant negative correlation was obtained for the concentration of serum thiobarbituric acid-reacting substances with the immunoreactive ceruloplasmin and its oxidase activity in the group of patients (p < 0.005). These results suggest that in RA increases of serum copper are produced at the expense of the fraction linked to the ceruloplasmin, diminishing the proportion of apoceruloplasmin and other forms poor in copper. Although the increase in the serum concentration of ceruloplasmin might offer an additional safeguard against oxidative stress. it does not appear to have a beneficial effect upon the activity of the illness as evaluated by means the biological inflammation markers C-reactive protein, erythrocyte sedimentation rate and sialic acid.

Identification of cytochrome P450 isoform involved in the metabolism of YM992, a novel selective serotonin re-uptake inhibitor, in human liver microsomes

1. In vitro studies were conducted to identify the hepatic cytochrome P450 isoform involved in the metabolism of YM992, ((S)-2-[[(fluoro-4-indanyl)oxy]methyl]morpholine monohydrochloride), a novel serotonin re-uptake inhibitor, in human liver microsomes. 2. Microsomes prepared from yeast expressing CYP1A1, CYP1A2 and CYP2D6 effectively metabolized YM992. A significant correlation was observed between the rate of YM992 metabolism and 7-ethoxyresorufin O-deethylation, CYP1A1/2 specific activity, in liver microsomes from 16 individual donors (r2 = 0.628, p < 0.001). Alpha-naphtoflavone and isosafrole, CYP1A1/2 inhibitors, suppressed the metabolism of YM992 in human liver microsomes in a concentration-dependent manner. 3. The metabolism of YM992 in human liver microsomes was inhibited by approximately 95% by antibodies which recognize both CYP1A1 and CYP1A2 whereas antibodies specific for CYP1A1 did not show inhibitory effects. 4. The same major metabolites, M6 and M7, were generated from YM992 after incubation with human liver microsomes and recombinant human CYP1A2. 5. These results suggest that the metabolism of YM992 in human liver microsomes is mainly catalysed by CYP1A2, and that YM992 might increase plasma concentration of concomitant drugs metabolized by CYP1A2 due to competitive inhibition.

Genetically distinct autosomal dominant posterior polar cataract in a four-generation Japanese family

PURPOSE

To describe the clinical findings of a form of posterior polar cataract in a large Japanese family and to determine whether the posterior polar cataract is causally related to other autosomal dominant cataracts with known genes, chromosomal locations, or both.

METHODS

Systemic and ocular histories were obtained and comprehensive ophthalmic examinations were performed in 15 of 37 members of the Japanese family. The posterior polar cataract was transmitted in an autosomal dominant manner through four generations. Although there is some variation in the degree of opacification, the posterior polar cataract in this family is characterized by progressive disk-shaped posterior subcapsular opacities. Genetic linkage analysis was performed with 41 polymorphic microsatellite markers located in chromosomal regions known for linkage to cataracts. Genomic DNA extracted from the 15 individuals was amplified by polymerase chain reaction, the genotype at the marker loci was determined in each family member, and the lod score was calculated at each locus.

RESULTS

Significant linkage of the posterior polar cataract was ruled out from the following 10 loci or chromosomal regions: 16q22 and 1p36, to which two forms of autosomal dominant posterior polar cataract have been assigned: 1q21-q25, 2q33-q35, 13cen, 17p13, 17q11-q12, 17q24, 21q22, and 22q, which are the regions responsible for other autosomal dominant congenital cataracts.

CONCLUSIONS

This study confirms the genetic heterogeneity of autosomal dominant posterior polar cataracts and demonstrates that the posterior polar cataract in this Japanese family is phenotypically and genetically distinct from previously mapped cataracts.

Induction of cell shape changes through activation of the interleukin-3 common beta chain receptor by the RON receptor-type tyrosine kinase

The RON receptor-type tyrosine kinase, a member of the hepatocyte growth factor receptor family, is a receptor for macrophage-stimulating protein (MSP). Recently, we observed that MSP induces morphological changes in interleukin (IL)-3-dependent Ba/F3 cells ectopically expressing RON. We show here that stimulation of those cells with either MSP or IL-3 increases tyrosine phosphorylation of proteins of 130, 110, 90, 62, and 58 kDa and induces similar morphological changes, accompanied by unique nuclear shape and redistribution of F-actin. A tyrosine kinase inhibitor, genistein, blocked both the increase in tyrosine phosphorylation and morphological changes. Upon stimulation with either MSP or IL-3, prominent tyrosine-phosphorylated pp90 was similarly co-immunoprecipitated with the common beta chain of IL-3 receptor (betac). Unlike IL-3, stimulation with MSP increased tyrosine phosphorylation of betac without activation of JAK2, resulting in morphological changes with modest cell growth. Confocal immunofluorescence analyses showed colocalization of RON, betac, and tyrosine-phosphorylated proteins. In vitro kinase assays revealed that autophosphorylated RON phosphorylated betac. These results suggest that the signaling pathway for morphological changes through betac and its associated protein pp90 is distinct from the pathway for cell growth in the IL-3 signal transduction system.

Crohn's disease associated with colo-bronchial fistula

An 18-year-old female patient with Crohn's disease presented with left lower lobe pneumonia and pleural effusion which were resistant to treatment with antibiotics. Colo-bronchial fistula had not been recognized until she coughed up yellow sputa with feculent odor and developed acute respiratory distress syndrome. This type of fistula is a rare complication of Crohn's disease, but the present case certainly alerts physicians to search for a fistula between the bronchus and gastrointestinal tract when encountering patients with Crohn's disease accompanied by antibiotic-resistant chronic pneumonia.

EEG in ulcerative colitis

Electroencephalographic tracings of 50 patients with ulcerative colitis (UC) were compared with those of 75 controls. In the UC patients a 24% incidence of abnormal tracings was found as compared with an 8% incidence in the controls. A higher incidence of abnormal electroencephalograms was found among active cases of UC than among those in remission. The meaning of these results is not yet clear.