Spatial predictors of immunotherapy response in triple-negative breast cancer

Immune checkpoint blockade (ICB) benefits some patients with triple-negative breast cancer, but what distinguishes responders from non-responders is unclear1. Because ICB targets cell-cell interactions2, we investigated the impact of multicellular spatial organization on response, and explored how ICB remodels the tumour microenvironment. We show that cell phenotype, activation state and spatial location are intimately linked, influence ICB effect and differ in sensitive versus resistant tumours early on-treatment. We used imaging mass cytometry3 to profile the in situ expression of 43 proteins in tumours from patients in a randomized trial of neoadjuvant ICB, sampled at three timepoints (baseline, n = 243; early on-treatment, n = 207; post-treatment, n = 210). Multivariate modelling showed that the fractions of proliferating CD8+TCF1+T cells and MHCII+ cancer cells were dominant predictors of response, followed by cancer-immune interactions with B cells and granzyme B+ T cells. On-treatment, responsive tumours contained abundant granzyme B+ T cells, whereas resistant tumours were characterized by CD15+ cancer cells. Response was best predicted by combining tissue features before and on-treatment, pointing to a role for early biopsies in guiding adaptive therapy. Our findings show that multicellular spatial organization is a major determinant of ICB effect and suggest that its systematic enumeration in situ could help realize precision immuno-oncology.

Short-term stability of wastewater samples for storage and shipment in the context of the EU Sewage Sentinel System for SARS-CoV-2

In the context of an EU-wide surveillance system for SARS-CoV-2 in wastewater, recommended by the European Commission, this study aims to provide scientific support to the adequacy of transport and storage conditions of samples both in terms of duration and samples temperature. Three laboratories in Slovenia, Cyprus and Estonia investigated the short-term, one-week, isochronous stability of wastewater samples by RT-qPCR based detection of SARS-CoV-2 genes. The results were tested for statistical significance to determine uncertainty of quantification and shelf-life, at testing temperatures of + 20 °C and - 20 °C, relative to reference at + 4 °C. Samples were collected from three urban wastewater treatment plant influents and analysed respectively for SARS-CoV-2 genes N1, N2 (Laboratory 1), N2, E (Laboratory 2) and N3 (Laboratory 3), with various analytical methods. For a period of 7/8 days at + 20 °C, decreasing trends of measured concentrations were observed for all genes resulting in instability according to the statistical analysis, while at - 20 °C the trend of variation was stable only for N1, N2 (Laboratory 1) and N3 (Laboratory 3). Trends for gene E concentrations at - 20 °C (Laboratory 2) could not be tested statistically for stability because of lack of data. Over a period of just 3 days at + 20 °C, the variation was statistically non-significant indicating stability for genes N1, E and N3 for laboratories 1, 2 and 3, respectively. Nonetheless, the outcome of the study presents evidence to support the choice of the selected temperature at which samples shall be preserved during storage before analysis or transport to the laboratory. The conditions (+4 °C, ∼ few days) chosen for EU wastewater surveillance are in accordance with these results, highlighting the importance of stability testing of environmental samples to determine the short-term analytical uncertainty.

Effectiveness of a phone-based nurse monitoring assessment and intervention for chemotherapy-related toxicity: A randomized multicenter trial

Purpose

Anticancer treatment-related toxicities can impact morbidity and mortality, hamper the administration of treatment, worsen the quality of life and increase the burden on the healthcare system. Therefore, their prompt identification is crucial. NICSO (Italian Network for Supportive Care in Cancer) conducted a nationwide randomized trial to evaluate the role of a planned, weekly phone-based nurse monitoring intervention to prevent and treat chemotherapy, targeted therapy- and immunotherapy-related toxicities. Here, we report the results from the chemotherapy arm.

Methods

This was a nationwide, randomized, open-label trial conducted among 29 Italian centers (NCT04726020) involving adult patients with breast, colon, or lung cancer and a life expectancy ≥6 months receiving adjuvant chemotherapy. Patients received either a weekly nurse monitoring phone call and an educational leaflet reporting practical advice about prevention and treatment of toxicities (experimental group) or the educational leaflet only (control group).

Results

The addition of a nurse monitoring intervention may help reduce time spent with severe toxicities (grade ≥3), particularly those less frequently reported in clinical practice, such as fatigue. When considering grade 1–2 AEs, times with mild/moderate diarrhea, mucositis, fatigue and pain were shorter in the experimental arm. Time spent without AEs was significantly longer in the experimental arms for all the toxicities. The requirement for special medical attention was comparable between groups.

Conclusion

This study suggests the need for implementing a better system of toxicity assessment and management for patients treated with adjuvant chemotherapy to promote effective preventive and/or therapeutic intervention against these events.

P-694 Dosage of exogenous gonadotropins is not related to blastocyst aneuploidy or cumulative live-birth rates in PGT-A cycles

Study question

Does dosage of gonadotropins affect aneuploidy rate rates or cumulative live birth rates (CLBRs) after the transfer of euploid embryos?

Summary answer

We did not find evidence that dosage gonadotropin influenced significantly the rate of aneuploidy and CLBRs after transfer of euploid embryos.

What is known already

Aneuploidy rates increase steadily with age, reaching >80% in women >42 years old. The goal of controlled ovarian stimulation obtaining more embryos to biopsy through the recruitment of several follicles, reaching more euploid embryos. However, several studies have suggested that a high response to stimulation might be embryotoxic and/or increase aneuploidy rates by enhancing the abnormal segregation of chromosomes during meiosis. Furthermore, a study on young donors showed differences in the euploidy rates, suggesting an iatrogenic etiology resulting from different stimulation methods.

Study design, size, duration

A multicenter retrospective study, with the preimplantation genetic test for aneuploidy (PGT-A) between January 2013 and January 2020 collected from clinics IVIRMA in Europe. 6832 cycles of in vitro fertilization (IVF) with PGT-A were included in the study

Participants/materials, setting, methods

A total of 62131 embryos were analyzed for ploidy status. Embryos that were subjected to chromosomal analysis were performed blastomere by aCGH (array Comparative Genomic Hybridization) or NGS (Next-Generation Sequencing) analysis. The embryos were biopsied on days 5 and 6. Women were divided into two age groups (<37 and ≥37 years old). Outcomes were compared between different total gonadotropin dosages (<3000 and ≥3000 IU), the dosage of hMG, and numbers of oocytes retrieved.

Main results and the role of chance

The total number of aneuploid embryos was 28336 of the 62131 embryos genetically screened using PGT-A. The embryonic aneuploidy rate was 59.4% (95%CI 58.5-60.3). In the group of women with gonadotropins dosage <3000 IU the embryonic aneuploidy rate was 59.7% (95%CI 58.7-60.8) and in the group with gonadotropins dosage ≥3000 IU was 58.7% (95%CI 57.1-60.3) with no significant difference between them (P = 0.279). In the group of younger patients (<37 y.o) the aneuploidy rate demonstrated no significant differences between patients who received low gonadotropin dosages and patients with high gonadotropin dosages (P = 0.06). Aneuploidy rates in the group of older patients (≥37 y.o) were similar regardless of gonadotropin dosing (P = 0.21). Dividing the according to the number of oocytes retrieved (10, 11-15, >15), the analysis of aneuploidy rate revealed no association between the gonadotropin dosages administrated depending on the total number of retrieved oocytes and age. The aneuploidy rate was also analyzed considering the administration of hMG, there was no statistical difference in the aneuploidy rate with low or high hMG dosages also when it was stratified by age. The cumulative live-birth rate in the groups of different gonadotropins dosage and different ages of patients was similar across the group.

Limitations, reasons for caution

The retrospective nature is the major limitation of this study, also patients included in the study received PGT-A using NGS and CGH arrays technology. The aCGH analysis used is less sensitive than more recent NGS technology.

Wider implications of the findings

Our study demonstrated that gonadotropin dosage did not affect aneuploidy rate or cumulative live-birth rates suggesting that the high doses of gonadotropins used in ART cycles may be safe.

Trial registration number

not applicable

P-507 Psychosocial and motivational drivers of the increased IVF engagement of infertile couples following Covid-19

Study question

What are the main psychosocial motivational factors behind the increased IVF adoption during the Covid-19 Pandemic?

Summary answer

During the Covid -19 Pandemic more time invested in marital relationships prompted infertile couples to act and engage in IVF treatments.

What is known already

The Covid 19 Pandemic has generated a sense of lack of control and fear for the future in many individuals. However, like several life-threatening events, it could also have positive effects, motivating people to take significant actions for their life course. Little has been reported on the consequences that the Pandemic has generated on the infertile couple’s attitude toward reproduction, IVF treatments engagement and childbearing desire. We aimed to address if during the Pandemic, there was an increase of IVF demand and what motivational factors prompted infertile patients to pursue IVF as compared to the pre-pandemic.

Study design, size, duration

This is a prospective multicenter observational control-case study assessing the relational, emotional, and environmental motivational factors driving infertile couples to purse their first IVF treatment during the Covid-19 Pandemic in different IVF clinics as Valencia, Madrid, Rome, and Chile. To assess the growth rate in IVF activity at recruiting sites, number of cycles was compared over a 18 months period between the pre-pandemic and pandemic. The survey was run between September 2021 to January 2022.

Participants/materials, setting, methods

An ad hoc survey was developed to explore the main relationship, emotional and socioeconomical factors responsible for the IVF engagement. The electronic survey was delivered to 13585 patients attending the recruiting clinics from December 2018 to March 2020 for Prepandemic and from March 2020 to December 2021 for the Pandemic ones, and they were asked to rate their agreement for each answer on a five-points Likert scale.

Main results and the role of chance

For most clinics, data derived from national patients only showed a significant IVF demand increase (5.5-8.7%) for all indicators (number of started ovarian stimulations, oocyte pickups, and embryo transfers). Of 13685 patients receiving the survey only 1556 (810 prepandemic, 746 pandemic, response rate: 11%) completed it. Demographic and infertility history data (including male/female, infertility length, previous children and miscarriages, ethnicity) were homogeneous between two groups. However, the infertility length and the proportion of donation cycles were slightly lower in the pandemic group (2.3 vs 2.1) years and 24.1% vs 19% for pre-pandemic and pandemic, respectively; p < 0.001). Only 25.34% (95%CI: 22.2-28.6) of Pandemic patients experienced their referral clinic closing, and 19.17% (95% CI: 16.4-22.1) public hospital closing, and 30.56% (95%CI:27.2-34.01) valued the use of telemedicine in the IVF positively. Interestingly, over 90.21% (95%CI:87.8-92.2) of pandemic patients started childbearing desire before the Pandemic, and about 68.63% (95%CI:65.1-71.9) knew already about their infertility. This suggests the Pandemic had represented a strong trigger for infertile patients to reframe their reproductive intention. Among all the motivational factors addressed in the survey, the increased time to invest in marital relationship was the stronger driver for pursuing IVF for Pandemic patients (OR:1.48; 95%CI: 1.16-1.89; p < 0.01).

Limitations, reasons for caution

Not all potential drivers for IVF attainment have been included in the survey and unexplored factors might have played a role. Other reasons for caution include the possibility of response bias. However, the prospective design and the large multicentre/international setting of the study helped mitigating the effect of specific/local confounding.

Wider implications of the findings

The knowledge gathered here will be crucial to design more effective strategies to cope with patients’ needs during the pandemic. Furthermore, this study can provide a valuable resource for understanding psychosocial factors responsible of the ongoing decline in the natality rate in many developed countries, such as disincentivizing couples’ relationships.

Trial registration number

not applicable

Efficacy of a nurse monitoring service at preventing disease- or therapy-related symptoms in patients receiving targeted therapy or immunotherapy

12118

Background: The safety profile of Targeted therapies (TT) and immunotherapy (IT) may be underestimated and negatively affect the clinical outcome. Methods: A nationwide, randomized, open-label trial (NCT04726020) conducted among 29 Italian centers involved two cohorts of 223 adult patients (pts) with a solid tumor, receiving TT (group B, 119 pts) or IT (group C, 104 pts). Pts were randomized to receive a weekly nurse monitoring phone call, together with an educational leaflet with some practical advice about toxicities (experimental arm), or only the educational leaflet (control arm). In the experimental arm, pts received their monitoring phone call before their treatment began, then every week for up to 16 weeks of treatment were completed. The primary objective was the evaluation of the difference in toxicities according to patient-reported outcome (PRO)-CTCAE. Results: Both arms were comparable in terms of pts’ characteristics (e.g. site of primary tumor, line of treatment). The adherence to the project (that is the completion of every expected call) was 62.1% in group B and 66.9% in group C. In group B, in the experimental arm, we found a higher number of pts without pain (53.7 vs 39.9%, p = 0.047); a trend of lower fatigue (29.2 vs 18%, p = 0.067) was also observed. In group C, a higher number of pts did not report fatigue (29.1 vs 17.5%, p = 0.043), shortness of breath (61.4 vs 38.5%, p = 0.002) or dry skin (72 vs 52.3%, p = 0.004). More pts also referred to be without pain (51.6 vs 38.8%, p = 0.065) and pruritus (75.9 vs 64.5%, p = 0.088), even if these difference were not statistically significant. Conclusions: The use of PRO assessment through active nurse monitoring might lead to a better tolerance of TT and IT with possible implications on pts’ quality of life and ultimately on treatment outcome. In particular, in the IT group, several symptoms were prevented from occurring, thus encouraging a major effort to implement such active monitoring in this population. Clinical trial information: NCT04726020.

Pathologic complete response (pCR) to neoadjuvant treatment with or without atezolizumab in triple negative, early high-risk and locally advanced breast cancer. NeoTRIP Michelangelo randomized study

BACKGROUND

High-risk triple negative breast cancers (TNBC) are characterized by poor prognosis, rapid progression to metastatic stage and onset of resistance to chemotherapy, thus representing an area in need of new therapeutic approaches. PD-L1 expression is an adaptive mechanism of tumour resistance to tumour infiltrating lymphocytes, which in turn are needed for response to chemotherapy. Overall, available data support the concept that blockade of PD-L1/PD-1 check-point may improve efficacy of classical chemotherapy.

PATIENTS AND METHODS

Two-hundred-eighty patients with TNBC were enrolled in this multicentre study (NCT002620280) and randomized to neoadjuvant carboplatin AUC 2 and nab-paclitaxel 125 mg/m² iv on days 1 and 8, without (N = 142) or with (N = 138) atezolizumab 1200 mg iv on day 1. Both regimens were given q3 weeks for 8 cycles before surgery and 4 cycles of an adjuvant anthracycline regimen. The primary aim of the study is to compare event-free survival, an important secondary aim was the rate of pathological complete remission (pCR defined as absence of invasive cells in breast and lymph nodes). The primary population for all efficacy endpoints is the intention-to-treat population.

RESULTS

The intention-to-treat analysis revealed that pCR rate after treatment with atezolizumab (48.6%) did not reach statistical significance compared to no atezolizumab [44.4%: odds ratio (OR) 1.18; 95% CI 0.74-1.89; P = 0.48]. Treatment-related adverse events were similar with either regimen except for a significantly higher overall incidence of serious adverse events and liver transaminases abnormalities with atezolizumab.

CONCLUSIONS

The addition of atezolizumab to nab-paclitaxel and carboplatin did not significantly increase the rate of pCR in women with TNBC. In multivariate analysis the presence of PD-L1 expression was the most significant factor influencing rate of pCR (OR 2.08). Continuing follow up for the event-free survival is ongoing, and molecular studies are under way.

Abstract P2-07-12: Triple negative breast cancer subtypes and early dynamics of the 27-gene IO score predict pCR in the NeoTRIPaPDL1 trial

Background A post-hoc of NeoTRIP trial showed that 27-gene IO score assessed on baseline samples is predictive of increased pathological complete response (pCR) with the addition of atezolizumab to carboplatin/nab-paclitaxel, whereas the LAR subtype has the lowest rate of pCR with and without atezolizumab (Bianchini G ESMO 2021). We evaluated 27-gene IO score and TNBC subtypes on biopsies collected during treatment, assessed biomarker dynamics, and studied the association with pCR. Methods In NeoTRIP, patients randomly received 8 cycles of nab-paclitaxel/carbo alone (CT) or with atezolizumab (CT/A). 258 patients were evaluable for pCR (Per-Protocol Population). We assessed IO score as binary and continuous variable, and the five 101-gene TNBC types (BL1, BL2, LAR, M, and MSL; Ring et al 2016) by RNA-seq on biopsies at baseline and day 1 of second treatment cycle (d1c2) (n: baseline 242/258, 94%; d2c2 161/258, 62%; paired 152/258, 59%). Forty-four paired samples were excluded due to lack of tumor cells at d1c2. PD-L1 (Ventana SP142) and sTILs data were available. We evaluated the association with pCR of biomarkers assessed at d1c2 and their dynamics from baseline. Results Frequency of TNBC types at d1c2 showed minor differences between arms (p = 0.055). TNBC type frequencies were 22.9% BL1, 11.4% BL2, 22.9% LAR, 21.4% M, and 21.4% MSL in the CT/A arm and 43.8% BL1, 6.2% BL2, 11.2% LAR, 21.2% M, and 17.5% MSL in the CT arm. Individual TNBC type changes from baseline to d1c2 were observed, but overall, it was not significant. Frequency of IO positive score at d1c2 was similar in CT and CT/A arm (p = 0.75). Only in CT/A, an increase from baseline to d1c2 was observed (30.9% to 49.3%, p = 0.04).Overall, TNBC types at d1c2 were predictive of pCR (p = 0.00002). Compared to BL1, LAR and M were associated with lower pCR rate in CT (OR = 0.09, 95% CI = 0.01-0.83, p = 0.034 for LAR; OR = 0.16, 95% CI = 0.04-0.66, p = 0.011 for M) and CT/A arm (OR = 0.05, 95% CI = 0.01-0.49, p = 0.010 for LAR; OR = 0.28, 95% CI = 0.06-1.28, p = 0.102). pCR rate in LAR was 11.1% and 6.2% in CT and CT/A arm, respectively. TNBC types were predictive of pCR independently of PD-L1 and sTILs.Continuous IO score at d1c2 was predictive of pCR in both CT/A (p = 0.004) and CT arms (p = 0.009). The binary IO score was significantly associated to higher pCR rate in CT/A arm only (OR = 5.42, 95% CI = 1.95-15.07, p = 0.001). A strong predictive value of the highest quartile of IO score compared to the lowest was observed in CT/A (OR = 14.73, 95% CI = 2.97-73.21, p = 0.001) and CT (OR = 4.38, 95% CI = 1.21-15.81, p = 0.024) arms. pCR rates for the highest and lowest quartiles were 72.2% vs 15.0% in CT/A and 65.2% vs 30.0% in CT arm. In CT/A binary IO score at d1c2 retained significance after adjustment for baseline PD-L1 and sTILs (p = 0.036).Combining baseline and d1c2 IO score, only d1c2 assessment was informative in CT arm. In CT/A arm, both biomarkers were informative, with assessment at d1c2 being more informative than baseline IO score when continuous scores were considered. Baseline binary IO score (OR = 25.0, 95% CI = 3.31-188.9, p = 0.002) and ΔIO score (d1c2-baseline) (OR = 11.3, 95% CI = 1.07-120.1, p = 0.044) retained significance. The combination of baseline and d1c2 binary IO score defined four groups with different likelihood of pCR: 73.7% vs 15.2% in positive/positive and negative/negative groups, respectively (OR = 15.68, 95% CI = 3.88-63.32, p = 0.0001). Conclusions Dynamic of IO score early on treatment was linked to likelihood of pCR independently of baseline biomarkers and may be an early surrogate of treatment benefit especially in atezolizumab arm. LAR and M are associated with lower pCR rate, suggesting that different therapeutic strategies may be beneficial. Combining baseline and on-treatment biomarkers can be more informative than baseline only of the complex tumor/immune co-evolution dynamic and of clinical outcome.

Citation Format: Matteo Dugo, Chiun-Sheng Huang, Daniel Egle, Begoña Bermejo, Claudio Zamagni, Robert S. Seitz, Tyler J. Nielsen, Marc Thill, Antonio Anton, Stefania Russo, Eva Maria Ciruelos, Brock L. Schweitzer, Douglas T. Ross, Barbara Galbardi, Richard Greil, Vladimir Semiglazov, Balázs Gyorffy, Marco Colleoni, Catherine Kelly, Gabriella Mariani, Lucia Del Mastro, Pinuccia Valagussa, Giuseppe Viale, Maurizio Callari, Luca Gianni, Giampaolo Bianchini. Triple negative breast cancer subtypes and early dynamics of the 27-gene IO score predict pCR in the NeoTRIPaPDL1 trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-07-12.

Abstract PD10-06: Predictive value of RT-qPCR 27-gene IO score and comparison with RNA-Seq IO score in the NeoTRIPaPDL1 trial

Background The identification of biomarkers for optimization of immune checkpoint inhibitors (ICI) treatment is an unmet clinical need. In the Phase III randomized trial, NeoTRIPaPDL1, a post-hoc analysis of whole transcriptome RNA-Seq data, previously showed that the 27-gene IO score is a potential predictive biomarker of increased pathological complete response with the addition of atezolizumab to carboplatin/nab-paclitaxel (Bianchini G ESMO 2021). However, the laboratory implementation of gene-expression signatures measured using RNA-seq is challenging. Therefore, we further assessed the predictive value of the IO score using a twenty-seven gene RT-qPCR assay on NeoTRIP samples, and compared to the previously reported RNA-Seq version of the assay. Methods The NeoTRIP study randomized patients to eight cycles of carboplatin/nab-paclitaxel (CT) with or without atezolizumab (CT/A). 258 patients were evaluable for pCR (breast and nodes) as Per-Protocol Population. We assessed the IO score as binary and continuous variables using the CAP/CLIA validated DetermaIO qPCR test (Saltman et al 2021) on pre-treatment core biopsies (n=220/258; 85.3%), all of which have RNA-Seq data available. We evaluated the association between IO score defined by RT-qPCR and RNA-Seq, and the association of the IO score defined by RT-qPCR test with PD-L1 IHC (Ventana SP142), stromal TILs (sTILs), and pCR. Results Comparison of continuous IO scores between the RT-qPCR assay and the RNA-Seq algorithm had a Pearson’s correlation of 0.94 (p < 0.0001). High agreement between categorical IO scores was also observed (Cohens’ kappa = 0.84; 95% confidence interval [CI] = 0.77-0.91; p < 0.0001). RT-qPCR IO score was balanced in the two arms (p = 0.65) with 44% and 40% positive patients in the CT and CT/A arms, respectively. The RT-qPCR IO score was correlated with both PD-L1 (Pearson’s r = 0.64; p < 0.0001) and sTILs (Pearson’s r = 0.67; p < 0.0001). Continuous IO score was significantly predictive of pCR in CT/A (Odds ratio [OR] = 3.12; 95% CI = 1.20-8.10; p<0.019), but not CT arm (OR = 1.28; 95% CI = 0.54-3.01; p = 0.578). Considering the binary IO score, OR were 2.87 [1.27-6.47] (p = 0.011) and 0.91 [0.43-1.93] (p = 0.812), in CT/A and CT, respectively (interaction test p = 0.043). The pCR rate for CT/A vs CT was 69.8% vs 46.9% in IO score positive [+22.9%, p = 0.046, Chi-squared test] and 44.6% vs 49.2% [-4.6%, p = 0.73] in IO score negative. A significant interaction was found between continuous PD-L1 and continuous IO-score (p = 0.006). Among PD-L1-neg, 9 patients were IO score positive (10.1%). The pCR rate in this group was 3/4 (75%) in the CT/A arm and 1/5 (20%) in CT arm. The predictive value of IO score by RT-qPCR was similar to RNA-Seq. Conclusions We observed a high level of agreement and concordance between IO scores assessed by RT-qPCR and RNA-Seq, indicating that the 27-gene IO assay and algorithm is robust and the choice of platform has limited impact. This finding also demonstrates the high quality of NeoTRIP RNA-Seq data. In this post-hoc analysis, IO score assessment by this CLIA validated RT-qPCR test was confirmed to be predictive of atezolizumab benefit over CT alone in a randomized trial.

Citation Format: Matteo Dugo, Chiun-Sheng Huang, Daniel Egle, Begoña Bermejo, Claudio Zamagni, Robert S. Seitz, Tyler J. Nielsen, Marc Thill, Antonio Anton, Stefania Russo, Eva Maria Ciruelos, Brock L. Schweitzer, Douglas T. Ross, Barbara Galbardi, Richard Greil, Vladimir Semiglazov, Balázs Gyorffy, Marco Colleoni, Catherine Kelly, Gabriella Mariani, Lucia Del Mastro, Pinuccia Valagussa, Giuseppe Viale, Maurizio Callari, Luca Gianni, Giampaolo Bianchini. Predictive value of RT-qPCR 27-gene IO score and comparison with RNA-Seq IO score in the NeoTRIPaPDL1 trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD10-06.

Abstract GS1-00: Single-cell spatial analysis by imaging mass cytometry and immunotherapy response in triple-negative breast cancer (TNBC) in the NeoTRIPaPDL1 trial

Background Immunecheckpoint inhibitors are effective in early and advanced TNBC, however only aminority of patients benefit making precision immune-oncology a major unmetneed. Imaging mass cytometry (IMC) enables high dimensional tissue imaging atsubcellular resolution for assessment of TNBC ecosystems, providing informationon cell type composition, functional status, and spatial organisation. Methods InNeoTRIP patients with TNBC were randomized to eight cycles ofnab-paclitaxel/carbo (CT) with/without atezolizumab (CTA). Forty-four proteinsspanning cancer cells and the tumor microenvironment (TME) were assessed onpre-treatment biopsies (n=243/280; 86.8% evaluable after QC). FFPE samples werelabelled with antibodies conjugated to isotopically pure rare earth metalreporters and profiled at one micron resolution by IMC. For each sample, wehave generated three high dimensional images that encompass the tumor,tumor-stroma interface and adjacent stroma. We investigated the association ofprotein expression assessed separately for epithelial and TME cells, cellphenotypes, and spatial architectures with PD-L1 status (Ventana SP142),stromal TILs, TNBC types and pathological complete response (pCR). 237 patients(84.6%) have both IMC and RNA-seq available allowing for comparison with genesignatures derived from HALLMARK,ConsensusTME immune cell types, and Nanostring. Results Across243 samples we identify just over one million single cells. By supervised clustering,we defined 37 robust cell phenotypes. PD-L1-positive tumors, high stromal TILsand TNBC type were characterized by extreme heterogeneity and unique cell-type andspatial TME composition. Severalbiomarkers demonstrated a significant test for interaction. Considering proteinexpression, GATA3 and CD20 on TME, HLA-DR in epithelial cells and Ki67 assessedboth in epithelial and TME, had a significant test for interaction (p <0.05). For all these biomarkers, high expression (above median) was associatedwith an increase of pCR of >10% in favour of atezolizumab, whereas lowerexpression group demonstrated a similar pCR rate among arms.Two cellphenotypes, PD-L1+IDO+ antigen presenting cells (APCs) and CD56+ neuroendocrine(NE) epithelial cells, had a significant test for interaction. Higherexpression of these biomarkers was associated with higher likelihood of pCR in CTAarm, but not in CT arm. For example, PD-L1+IDO+APCs in the CTA arm wereassociated with pCR proportions of 64.6% and 24.6% for above- and below-mediangroups respectively (OR4.5 [2.01-10.1], p<0.001).Mostof these tests of interaction retained significance after adjustment by PD-L1status and stromal TILs. Notably, none among 61 gene-expression basedimmune-related pathways and 7 proliferation-related signatures demonstrated a significant test ofinteraction. Resultsof systematic multi-tiered image analysis at the levels of cell-cellinteractions and recurrent higher order multicellular complexes defining TNBC ecosystemsidentified by graph-based methods will be presented at the meeting. Conclusions Imaging mass cytometry provides a morecomprehensive overview of TNBC heterogeneity at a single-cell level withspatial resolution. Bulk protein or gene expression might deliver limitedpredictive information because it does not consider the cell compartment ofexpression. Precise cell phenotyping highlights the predictive role ofPD-L1+IDO+APCs and CD56+NE epithelial cells. Overall, we demonstrated that IMCis feasible in a large, randomized trial and provides independent predictiveinformation on immune checkpoint inhibitors benefit to PD-L1, TILs and gene-expressionprofiles.

Citation Format: Giampaolo Bianchini, Xiao Qian Wang, Esther Danenberg, Chiun-Sheng Huang, Daniel Egle, Maurizio Callari, Begoña Bermejo, Claudio Zamagni, Marc Thill, Anton Anton, Matteo Dugo, Stefania Zambelli, Stefania Russo, Eva Maria Ciruelos, Richard Greil, Vladimir Semiglazov, Marco Colleoni, Catherine Kelly, Gabriella Mariani, Lucia Del Mastro, Balázs Győrffy, Olivia Biasi, Pinuccia Valagussa, Giuseppe Viale, Luca Gianni, H Raza Ali. Single-cell spatial analysis by imaging mass cytometry and immunotherapy response in triple-negative breast cancer (TNBC) in the NeoTRIPaPDL1 trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr GS1-00.

Implant rehabilitation of edentulous jaws with predominantly monolithic zirconia compared to metal-acrylic prostheses: a 2-year retrospective clinical study

Limited data are available on the clinical outcomes of patients with edentulism treated with predominantly monolithic zirconia fixed complete dentures (FCDs) compared to traditional restoration materials. The purpose of this study was to analyze the differences in terms of complications and failures of definitive full-arch implant rehabilitations made in metal-acrylic versus those made in monolithic zirconia with porcelain veneering limited to non-functional areas. This retrospective clinical study included 50 patients treated between January 2015 and December 2018, with 222 implants inserted in fifty edentulous jaws. All patients were treated with immediately loaded full-arch fixed prostheses (22 maxillary; 28 mandibular) each supported by four to six implants (two/four axial, two distally tilted). All 25 zirconia prostheses were predominantly monolithic with ceramic veneering limited to non-functional areas. The primary outcome measures were prosthetic success of the definitive restoration and implant survival. The secondary outcome measures were full mouth plaque score, full mouth bleeding score, peri-implant probing depths and periimplant keratinized tissue. All implants and prostheses analyzed had a minimum of 2 years of followup. No chipping of the veneered facial porcelain or other technical complication was observed over the study period achieving a prosthesis survival and success rate of 100%. No implants were lost, achieving a 100% survival rate. Bleeding on probing was positive in 33% and 13% of probing sites for metal-acrylic prosthesis and zirconia prosthesis, respectively (p = 0.0445). Plaque index was positive in 76% and 53% of probing sites for metal-acrylic prosthesis and zirconia prosthesis, respectively (p = 0.0491). Mean probing depth was 1.74mm (SD 0.89mm) for the 106 implants supporting metal-acrylic prosthesis and 1.52mm (SD 0.63mm) for the 116 implants supporting zirconia prosthesis (p=0.0412). No other statistically significant differences were found between the two groups. The results of this retrospective evaluation showed that predominantly monolithic zirconia is a feasible alternative to the conventional metal framework acrylic for full arch implant-supported prosthesis. The restauration material did not influence the failure rate and complication risk of both prosthesis and implants.

Bleeding complications in patients with squamous cell carcinoma of the head and neck

Hemorrhage in recurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) may be attributed to chemotherapy and local tumor irradiation. Evidence of the relationship between hemorrhage in R/M HNSCC and targeted therapies, including epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) inhibitors, or immune checkpoint inhibitors, is limited. We aimed to identify epidemiological and clinical data related to the occurrence of hemorrhage in R/M HNSCC and to explore its relationship with various therapies. We describe information obtained from literature searches as well as data extracted from a commercial database and a database from the author's institution (Istituto Nazionale dei Tumori of Milan). Evidence suggests that most bleeding events in R/M HNSCC are minor. Clinical trial safety data do not identify a causal association between hemorrhage and anti‐EGFR agents or immune checkpoint inhibitors. In contrast, anti‐VEGF agents are associated with increased, and often severe/fatal, hemorrhagic complications.

Abstract PS12-22: Maintenance therapy with everolimus plus aromatase inhibitors vs aromatase inhibitors as after first-line chemotherapy in HR+/HER2- metastatic breast cancer: Updated analyses of the phase III randomized MAIN-A trial

Background Despite endocrine therapy is the mainstay of treatment for HR+/HER2- metastatic breast cancer (MBC), patients with high disease burden or those at risk of visceral crisis are still offered first-line chemotherapy (CT). Chemotherapy is generally followed by maintenance hormonal therapy. The MAIN-A study is an investigator-driven, randomized phase III trial designed to compare maintenance everolimus (EVE) combined with aromatase inhibitors (AI) versus AI alone in pts with disease control after first-line CT.Methods Postmenopausal pts achieving disease control (stable disease, partial response or complete response) after first-line CT were randomly assigned to EVE 10 mg po daily plus AI or to AI alone. Primary aim was PFS in the ITT. We present here overall survival (OS) results and the impact of tumor characteristics on PFS.Results 110 pts were randomized to EVE+AI (n=52) or to AI (n= 58). Primary aim results have been already presented (Guarneri V, ESMO Breast 2019), showing a non-significant prolongation of median PFS in the ITT population for EVE+AI (9.9 mos vs 7.2 mos, HR 0.764, 95% CI 0.501-1.164. Patients with visceral metastases tended to experience shorter PFS as compared with patients with patients with bone/soft tissues metastases (median 11.1 mos vs 6.4 mos, p=0.0746). The levels of estrogen receptor expression (>or< 50%) did not impact PFS, overall and by treatment arm. At the time of this writing, a total of 61 death events have been recorded. No difference in OS was observed between the two arms (median 33.9 mos for EVE+AI vs 33.5 mos for AI, HR 0.97, 95% CI 0.59-1.61).Conclusions Maintenance EVE+AI did not significantly impact on the outcome of metastatic breast cancer patients deemed suitable for first line chemotherapy.

Citation Format: Valentina Guarneri, Saverio Cinieri, Maria Vittoria Dieci, Carmelo Bengala, Gabriella Mariani, Giancarlo Bisagni, Antonio Frassoldati, Claudio Zamagni, Laura Orlando, Carlo Alberto Giorgi, Gian Luca De Salvo, PierFranco Conte. Maintenance therapy with everolimus plus aromatase inhibitors vs aromatase inhibitors as after first-line chemotherapy in HR+/HER2- metastatic breast cancer: Updated analyses of the phase III randomized MAIN-A trial [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 PS12-22.

The unfinished work of neonatal very low birthweight infants quality improvement: Improving outcomes at a continental level in South America

Neonatal mortality rate varies between 4.2 and 18.6 per thousand by country in South America. There is little information regarding the outcomes of very low birth weight infants in the region and mortality rates are extremely variable ranging from 6% to over 50%. This group may represent up to 50-70% of the neonatal mortality and approximately 25-30% of infant mortality. Some initiatives, like the NEOCOSUR Network, have systematically collected and analyzed epidemiological information on VLBW infants' outcomes in the region. Over a 16-year period, survival without major morbidity improved from 37 to 44%. However, mortality has remained almost unchanged at approximately 27%, despite an increase in the implementation of the best available evidence in perinatal practices over time. Implementing quality improvement initiatives in the continent is particularly challenging but represents a great opportunity considering that there is a wide margin for progress in both care and outcomes.

Antitumor activity and efficacy of shorter versus longer duration of anthracycline-taxane neoadjuvant chemotherapy in stage II-III HER2-negative breast cancer: a 10-year, retrospective analysis

Background:

Neoadjuvant anthracycline-taxane-based chemotherapy (ChT) is a standard of care treatment option for stage II–III breast cancer (BC) patients. However, the optimal duration of neoadjuvant ChT has been poorly investigated so far.

Material and methods:

We retrospectively retrieved clinical data of patients with stage II–III human epidermal growth factor receptor 2-negative (HER2–) BC who were treated between October 2007 and January 2018 with neoadjuvant AT (doxorubicin-paclitaxel) for three cycles followed by CMF (cyclophosphamide-methotrexate-5-fluorouracil) for three cycles (cohort A) or with four AT cycles followed by four CMF cycles (cohort B). The aim of our study was to investigate the impact of neoadjuvant ChT duration (cohort A versus cohort B) on pathological complete response (pCR) rates, disease-free survival (DFS) and overall survival (OS).

Results:

Of 209 HER2– BC patients included, 62 had triple-negative breast cancer (TNBC) and 147 had hormone receptor-positive (HR+) BC. Median age was 48 years (range 30–74 years). A total of 111 patients belonged to cohort A and 98 patients belonged to cohort B. pCR was detected in 29 (13.9%) patients, 25 (40.3%) of whom had TNBC and four (2.7%) had HR+ HER2– BC. Patients achieving pCR had significantly longer DFS and OS, with statistical significance reached only in patients with TNBC. We found no differences between cohort A and cohort B in terms of pCR rates (15.3% versus 12.2%; p = 0.55), DFS (p = 0.49) or OS (p = 0.94). The incidence of grade 3/4 adverse events was similar in cohort A versus cohort B as well (22.5% versus 19.4%; p = 0.54).

Conclusion:

Shorter duration of neoadjuvant anthracycline-taxane ChT was not associated with worse clinical outcomes in patients with stage II–III BC. Prospective studies are needed to evaluate whether the duration of neoadjuvant anthracycline-taxane-based ChT can be reduced in specific patient subgroups without negatively affecting clinical outcomes.

PETC/CT with 18F-Choline localizes hyperfunctioning parathyroid adenomas equally well in normocalcemic hyperparathyroidism as in overt hyperparathyroidism

PURPOSE

Identification of pathologic parathyroid glands in primary hyperparathyroidism, traditionally based on neck ultrasound (US) and/or ^99mTc-Sestamibi scintigraphy, can be challenging. PET/CT with ¹⁸F-Fluorocholine (¹⁸F-FCH) might improve the detection of pathologic parathyroid glands. We aimed at comparing the diagnostic performance of ¹⁸F-FCH-PET/CT with that of dual-phase dual-isotope parathyroid scintigraphy and neck US.

METHODS

Thirty-four consecutive patients with primary hyperparathyroidism were prospectively enrolled, 7 had normocalcemic hyperparathyroidism, and 27 had classic hypercalcemic hyperparathyroidism. All patients underwent high-resolution neck US, dual-phase dual-isotope ^99mTc-Pertechnetate/^99mTc-Sestamibi scintigraphy, and ¹⁸F-FCH-PET/CT.

RESULTS

In the whole patients' group, the detection rates of the abnormal parathyroid gland were 68% for neck US, 71% for ¹⁸F-FCH-PET/CT, and only 15% for ^99mTc-Sestamibi scintigraphy. The corresponding figures in normocalcemic and hypercalcemic hyperparathyroidism were 57 and 70% for neck US, 70 and 71% for ¹⁸F-FCH-PET/CT, and 0 and 18% for ^99mTc-Sestamibi scintigraphy, respectively. In the 17 patients in whom the abnormal parathyroid gland was identified, either at surgery or at fine needle aspiration cytology/biochemistry, the correct detection rate was 82% for neck US, 89% for ¹⁸F-FCH-PET/CT, and only 17% for ^99mTc-Sestamibi scintigraphy.

CONCLUSIONS

¹⁸F-FCH-PET/CT can be considered a first-line imaging technique for the identification of pathologic parathyroid glands in patients with normocalcemic and hypercalcemic hyperparathyroidism, even when the parathyroid volume is small.

Single Institution trial of anthracycline- and taxane-based chemotherapy for operable breast cancer: The ASTER study

The efficacy of anthracycline- and taxane-based chemotherapy for perioperative treatment of breast cancer (BC) has been established. No superiority of a cytotoxic regimen has been demonstrated, provided that administration of an anthracycline and a taxane is warranted. The ASTER study was designed to investigate the safety of 6 months of perioperative chemotherapy with Doxorubicin and Paclitaxel, followed by Cyclophosphamide, Methotrexate, and 5-Fluorouracil. ASTER enrolled patients with cT2-3 N0-1 or pT1-2 N1-3 BC, from November 2008 to August 2011. Treatment consisted of Doxorubicin 60 mg/sm, Paclitaxel 200 mg/sm q21 (AT) for three cycles followed by Cyclophosphamide 600 mg/sm, Methotrexate 40 mg/sm, 5-Fluorouracil 600 mg/sm d1,8 q28 (CMF) for three cycles, in either neo-adjuvant or adjuvant setting. All HER-positive patients received targeted therapy with Trastuzumab for 1 year. Disease-free and overall survival (DFS and OS, respectively) were estimated according to Kaplan-Meier method. Three hundred and thirty patients were enrolled, where 77.9% of cases were treated in an adjuvant setting; 65.5% received breast conservative surgery, 72.4% axillary dissection. 75.5% of cases presented estrogen receptor positivity, 66.7% progesterone receptor positivity; 18.5% of patients presented HER2-positive BC, 16.1% triple negative disease. Twenty-eight (8.5%) developed grade III-IV hematologic toxicity; nine patients (2.7%) developed grade III neurological toxicity. Loco-regional DFS was 99.6% at 1 year, 97.1% at 5 years, 95.9% at 7 years. Corresponding distant DFS was 98.4%, 90.2%, and 88.8%. One, 5, and 7-year OS was 99.6%, 94.9%, and 91.2%, respectively. Chemotherapy with ATx3→CMFx3 is confirmed safe and effective at 6.7 years follow-up. These results appear comparable to those reported in regulatory trials of most commonly prescribed anthracycline and taxane-based regimens.

Radiotherapy with the anti-programmed cell death ligand-1 immune checkpoint blocker avelumab: acute toxicities in triple-negative breast cancer

Triple-negative breast cancer (TNBC) is clinically the most aggressive breast cancer (BC) subtype. There is an urgent need for effective therapies for patients with TNBC. Recent findings confirm the important role of factors related to the immune system in the clinical outcome and response to treatment of TNBC patients. Avelumab selectively binds to PDL1, and competitively blocks its interaction with anti-programmed death 1 (anti-PD-1) antibodies. Unlike anti-PD-1 antibodies, which target T-cells, avelumab targets tumor cells, and is therefore expected to have fewer side effects, including a lower risk of Immune-Related Adverse Events (irAEs). Uncertainties remain regarding a potential synergy resulting in increased toxicities by combining radiotherapy and immune-checkpoint inhibitors (ICIs). Effects of concomitant ICIs with thoracic radiotherapy on pulmonary toxicities is not currently known. There are no published data available on the effects of combining anti-PD-L1 with adjuvant radiotherapy (RT) for BC in a clinical setting. We reported a preliminary experience on the first patient treated at the National Cancer Institute of Milan with the association of avelumab and concomitantly RT for TNBC.

Comparison Between Subcutaneous and Intravenous DDAVP in Mild and Moderate Hemophilia A

Sixteen patients with mild and moderate hemophilia were given Desmopressin (DDAVP) subcutaneously in the absence of any actual bleeding. The response to the drug – in terms of factor VIII coagulant activity rise – became apparent 15 min after the injection, reaching the maximal response after one hour (x̄ 3.2 times the baseline levels; SD 1.21). This response was not different from that elicited using the intravenous route in 18 hemophiliacs of comparable severity after the same time interval. No local or general side-effects were recorded after the subcutaneous administration of DDAVP. We therefore conclude that the subcutaneous route adds further evidence to the reliability of this alternative treatment in mild factor VIII deficiencies, thus making home treatment with this vasopressin analogue possible.

Factor VII Activity and Antigen in Haemophilia B Variants

Twenty three patients belonging to 18 different pedigrees of Haemophilia B were studied with regard to ox-brain prothrombin time and its correlation to factor VII.

Eleven among them were B-negative (no detectable factor IX antigen), five were B-reduced (factor IX antigen detectable but below the normal values) and seven were B-positive (normal levels of factor IX antigen).

Ox-brain prothrombin time was found prolonged (≥ x̄ + 2.5 SD:99% confidence limits) in nine patients. Factor VII Activity (VII: C) was found reduced in 1/11 B-negative, in 2/5 B-reduced and in 4/7 B-positive patients. Factor VII Antigen (VII: Ag) was found normal in all but one patient.

The ratio VII:C/VII:Ag was abnormal in eight patients independently from the variant of Haemophilia B. The underlying defect which causes the prolongation of Ox-brain prothrombin time due to factor VII: C mild deficiency is heterogeneous. Age, a mild Vitamin K deficiency, the presence of an inhibitor of Factor VII activation and other unknown causes, may be responsible for this pattern.

Treatment of Congenital Factor VII Deficiency with a New Concentrate

A new factor VII concentrate, made from ACD plasma by a process involving successive absorptions of cryoprecipitate supernatant on DEAE Sephadex and of the resulting supernatant on Al(OH)3, was administered to 10 patients with severe factor VII deficiency. 5 patients received only one dose for treatment of a single bleeding episode, the remaining 5 were given multiple infusions (47) for spontaneous hemorrhages or for the prevention of surgical bleeding. In vivo factor VII recovery ranged from 43 to 126% (average 88%) of the assayed in vitro activity of the concentrate. A dose of 0.5 u/kg was found to produce a 1% rise of the plasma factor VII levels. The mean half-life on injected factor VII as assessed in 7 kinetic studies was 205 min (range 168-234). Spontaneous bleeding was easily controlled by the concentrate and major surgical procedures (two tonsillectomies) could be performed without complications. 1 patient developed HBsAg positive hepatitis, but otherwise no serious side effects were observed. Factor VII concentrate reduces the risk of precipitating circulatory overload associated with the use of plasma and avoids the unnecessary rise of factor II, IX and X which follows prothrombin complex concentrates.

Immune Tolerance in Hemophilia-Principal Results from the International Registry

40 Hemophilia Centers from the USA, Canada, Europe and Japan referred to the International Registry 204 patients with haemophilia A, treated by Immune Tolerance (IT) Protocols over the past two decades because of the presence of an inhibitor to FVIII. 82% of the patients were high responders, while IT was started with low levels of inhibitor (<10 BU) in most (57.3%) of the cases. 69 patients (33.8%) were given the highest FVIII dosage (≥200 IU/kg/day), 71 (34.8%) intermediate dosages (50 - <200) and 64 (31.4%) the lowest dosages (<50). Of 158 patients persevering with treatment long enough to judge the outcome thereof, 107 (67.7%) achieved tolerance, 12 (7,6%) had a partial response, while 39 (24.7%) did not respond. Multivariate logistic regression analysis showed that two variables were independently associated with the highest probability of success: the use of high dose protocols (≥100 IU/kg/day) (p <.0001) and the presence of low levels of inhibitor (<10 BU) at enrollment (p = .004). The Kaplan-Meier inhibitor-free survival curve showed that tolerance is longlasting: only 1 out of 107 patients relapsed and the longest documented tolerant patient has been inhibitor-free for 16 years. 129 hemophiliacs were HIV Ab-negative at enrollment; of the 118 HIV-screened after the treatment, 18 (13.9%) were found to be HIV Ab-positive. IT can indeed modify the natural history of inhibitors to FVIII in hemophilia.

Detection of New Polymorphic Markers in the Factor V Gene: Association with Factor V Levels in Plasma

Three novel polymorphisms were found in the repeated region of the large exon 13 of factor V gene, one giving rise to a codon dimorphism (Serl240) and two causing aminoacid substitutions (Hisl299Arg, Leul257Ile). An increasing frequency of the Argl299 (R2 allele) correlated with a decreasing mean plasma factor V activity in the groups of subjects under study, which included 26 unrelated subjects with partial factor V deficiency. Family studies supported the co-inheritance both of low factor V activity and of R2 allele. The reduction of factor V activity associated with the R2 allele was not clinically symptomatic even in the homozygous condition and was characterized by a parallel reduction of antigen in plasma, in which abnormal molecules were not detected. Data suggest that the R2 allele represents a marker in linkage with an unknown defect rather than a functional polymorphism.

These studies provide the first evidence of a genetic component in determining factor V levels in plasma and of a genetic linkage between the factor V gene and factor V deficiency. They also define specific haplotypes which are associated with factor V deficiency or with APC resistance (Arg506Gln) and are valuable fools for the study of factor V defects.

Inhibition of Protein S by Autoantibodies in Patients with Acquired Protein S Deficiency

This study was undertaken to analyze antibodies to protein S (PS) in patients with an acquired PS deficiency. Plasma from symptomatic patients with acquired (n = 14) or congenital (n = 10) PS deficiency and 10 healthy donors was screened for PS antibodies by immunoblotting and for anti-phospholipid antibodies. PS antibodies (IgG) were detected in five of the patients with acquired PS deficiency. These antibodies belonged to the G1 and G4 immunoglobulin subclasses. IgG fractions from the same 5 patients were shown to inhibit PS activity. The inhibition of PS activity by the 5 IgG fractions was shown to be time-and dose-dependent and was abolished following incubation with purified PS, while no effect was found after absorption with cardiolipin micelles. In addition, anticardiolipin monoclonal or human purified antibodies, failed to exert significant PS inhibition. These findings demonstrate that anti-PS antibodies are able to inhibit PS activity and that this is independent of anti-phospholipid antibodies. Given the clinical features of the patients, these antibodies should be regarded as an expression of the broad autoimmune syndrome involving the phospholipid-binding plasma proteins.

Induction of Immunotolerance in Hemophilia for High Titre Inhibitor Eradication: A Long-Term Follow-Up

Three hemophiliacs with high titre inhibitor were treated with a medium-high FVIII dose schedule (100 IU/kg bw daily) with the aim of inducing the immunotolerance. These patients were followed-up extensively concerning their immunological status and HIV serology. In all of them the inhibitor disappeared and normal FVIII kinetics were obtained after 22, 15 and 29 months. After eradication of the inhibitor, no recurrence took place in any of the patients. All the patients were HIV Ab positive before the beginning of the treatment. In one of them CD4+ cells fell progessively 32 months after the treatment was started, a fullblown AIDS showed up, and the patient died 5½ years after the beginning of the treatment. In the second and third patient the CD4+ cells varied widely but remained >400/μl during the whole immunotolerance treatment. The latter two patients are AIDS and ARC free so far, but patient No. 2 developed a mild-to-severe thrombocytopenia.

Considering the high cost of the treatment and the possibility that such an intensive administration of FVIII concentrates might worsen the immunological status of patients, this therapeutic procedure should only be applied with caution.

Concentrated DDAVP: Further Improvement in the Management of Mild Factor VIII Deficiencies

This study was carried out to evaluate the pharmacological efficacy of a new concentrated 1 Deamino - (8-D-arginine) - vasopressin (DDAVP) preparation. Concentrated DDAVP (C- DDAVP), (40 μg/mL) was given subcutaneously (s.c.) in hemophilia and von Willebrand Disease (vWD), and the response was evaluated in terms of factor VIII/vWF (VUI/von Willebrand Factor) complex response. This response was also compared to that obtained using the currently available commercial preparation (4 μg/mL) given either s.c. or intravenously (i. v.). The maximal f. VIII response after s.c. C-DDAVP was reached one hour after the injection (x:3.6 times the resting values) with an average decline of 15% at two hours. The response to s.c. C- DDAVP in patients with hemophilia was slightly better than thut obtained with the diluted brand, but the difference did not reach any statistical significance even when the schedules were compared in the same patients. In type I (placed normal subtype) vWD, a higher response in terms of factor VIII :C increase in comparison with hemophiliacs was obtained. Doth Ristocetin cofactor activity (RiCof) and bleeding time responded to this vasopressin analogue, when administered subcutaneously.

SELECT-2: a phase II, double-blind, randomized, placebo-controlled study to assess the efficacy of selumetinib plus docetaxel as a second-line treatment of patients with advanced or metastatic non-small-cell lung cancer

Background

Combination of selumetinib plus docetaxel provided clinical benefit in a previous phase II trial for patients with KRAS-mutant advanced non-small-cell lung cancer (NSCLC). The phase II SELECT-2 trial investigated safety and efficacy of selumetinib plus docetaxel for patients with advanced or metastatic NSCLC.

Patients and methods

Patients who had disease progression after first-line anti-cancer therapy were randomized (2 : 2 : 1) to selumetinib 75 mg b.i.d. plus docetaxel 60 or 75 mg/m² (SEL + DOC 60; SEL + DOC 75), or placebo plus docetaxel 75 mg/m² (PBO + DOC 75). Patients were initially enrolled independently of KRAS mutation status, but the protocol was amended to include only patients with centrally confirmed KRAS wild-type NSCLC. Primary end point was progression-free survival (PFS; RECIST 1.1); statistical analyses compared each selumetinib group with PBO + DOC 75 for KRAS wild-type and overall (KRAS mutant or wild-type) populations.

Results

A total of 212 patients were randomized; 69% were KRAS wild-type. There were no statistically significant improvements in PFS or overall survival for overall or KRAS wild-type populations in either selumetinib group compared with PBO + DOC 75. Overall population median PFS for SEL + DOC 60, SEL + DOC 75 compared with PBO + DOC 75 was 3.0, 4.2, and 4.3 months, HRs: 1.12 (90% CI: 0.8, 1.61) and 0.92 (90% CI: 0.65, 1.31), respectively. In the overall population, a higher objective response rate (ORR; investigator assessed) was observed for SEL + DOC 75 (33%) compared with PBO + DOC 75 (14%); odds ratio: 3.26 (90% CI: 1.47, 7.95). Overall the tolerability profile of SEL + DOC was consistent with historical data, without new or unexpected safety concerns identified.

Conclusion

The primary end point (PFS) was not met. The higher ORR with SEL + DOC 75 did not translate into prolonged PFS for the overall or KRAS wild-type patient populations. No clinical benefit was observed with SEL + DOC in KRAS wild-type patients compared with docetaxel alone. No unexpected safety concerns were reported.

Trial identifier

Clinicaltrials.gov NCT01750281.

Breast Microcalcifications Studied with 3d Contrast-enhanced High-field Magnetic Resonance Imaging: More Accuracy in the Diagnosis of Breast Cancer

Aims

To evaluate the reliability of magnetic resonance imaging (MRI) performed with three-dimensional (3D) sequences in mammographically detected breast microcalcifications.

Methods

During an 8-month period, a group of 28 patients with mammographically detected microcalcifications suspicious for malignancy underwent MRI. Their ages ranged from 33 to 65 years. Examinations were performed with a 1.5 Tesla MR unit and a 3D T1 weighted sequence. Images were interpreted on the basis of morphologic parameters and dynamic behavior in the uptake of contrast medium (Gd-DTPA). Histologic findings were considered as the gold reference.

Results

Histologic analysis revealed invasive carcinoma in 7 patients, 3 of which were associated with foci of lobular carcinoma in situ. Intraductal carcinoma was diagnosed in 8 patients, 1 of which was associated with a tubular carcinoma. Benign lesions accounted for 13 patients. All the neoplastic conditions showed enhancement on MR images (sensitivity, 100%), whereas early and intense enhancement was noted in 5 of 13 benign lesions (specificity, 61%). The positive predictive value was 75% and negative predictive value, 100%.

Conclusions

Although an overlap in the enhancement behavior of malignant and some benign lesions is clearly evident, a careful interpretation of MR images is helpful in detecting and mainly ruling out breast cancer combined with mammographically suspicious microcalcifications.

Hypofractionated Whole-Breast Irradiation With or Without Boost in Elderly Patients: Clinical Evaluation of an Italian Experience

PURPOSE

To examine local control, disease-free survival (DFS), and toxicity in elderly (≥ 65 years) breast cancer patients treated with hypofractionated radiotherapy (hypo-RT) with or without a boost to the tumor bed.

PATIENTS AND METHODS

The study was conducted on 752 patients treated from April 2009 to February 2017. Patients received 42.4 Gy in 16 daily fractions (2.65 Gy per fraction). A boost was only administered in cases of grade 3 primary tumor and close or positive margins. Acute and late toxicity was prospectively assessed during and after hypo-RT, based on the Radiation Therapy Oncology Group scale. DFS and local recurrence-free survival were estimated by the Kaplan-Meier method for cumulative probability. Log-rank tests were used to identify differences by subtype. Cox proportional hazard models were used to investigate the impact of various factors on the risk of disease progression.

RESULTS

Among the 752 patients treated, 41 (5.5%) experienced disease progression, including 7 (17.1%) exclusively local recurrences; 1 (2.4%) local and nodal recurrence; 1 (2.4%) local and nodal recurrence plus metastasis; 7 (17.1%) nodal recurrences plus metastases; and 25 (61%) exclusively distant metastases. The 5-year DFS, local recurrence-free survival, breast cancer-specific survival, and overall survival rates were 91.8% (95% confidence interval [CI], 88.6-94.2), 98.0% (95% CI, 96.1-99.1), 98.2% (95% CI, 96.5-99.1), and 87.5% (95% CI, 83.8-90.5), respectively. On univariate analysis, the administration of a boost, disease grade (grades 1 and 2 vs. 3), and molecular subtype (triple negative or human epidermal growth factor receptor 2 [HER2] positive, or luminal B vs. luminal A) significantly affected disease progression (P < .01). These findings were confirmed by multivariate analysis.

CONCLUSION

Hypo-RT is effective and well tolerated in the elderly population, and the routine use of a boost for patients over 65 years is not justified. Further studies on the boost issue are strongly advocated.

Selumetinib in Combination With Dacarbazine in Patients With Metastatic Uveal Melanoma: A Phase III, Multicenter, Randomized Trial (SUMIT)

Purpose Uveal melanoma is the most common primary intraocular malignancy in adults with no effective systemic treatment option in the metastatic setting. Selumetinib (AZD6244, ARRY-142886) is an oral, potent, and selective MEK1/2 inhibitor with a short half-life, which demonstrated single-agent activity in patients with metastatic uveal melanoma in a randomized phase II trial. Methods The Selumetinib (AZD6244: ARRY-142886) (Hyd-Sulfate) in Metastatic Uveal Melanoma (SUMIT) study was a phase III, double-blind trial ( ClinicalTrial.gov identifier: NCT01974752) in which patients with metastatic uveal melanoma and no prior systemic therapy were randomly assigned (3:1) to selumetinib (75 mg twice daily) plus dacarbazine (1,000 mg/m2 intravenously on day 1 of every 21-day cycle) or placebo plus dacarbazine. The primary end point was progression-free survival (PFS) by blinded independent central radiologic review. Secondary end points included overall survival and objective response rate. Results A total of 129 patients were randomly assigned to receive selumetinib plus dacarbazine (n = 97) or placebo plus dacarbazine (n = 32). In the selumetinib plus dacarbazine group, 82 patients (85%) experienced a PFS event, compared with 24 (75%) in the placebo plus dacarbazine group (median, 2.8 v 1.8 months); the hazard ratio for PFS was 0.78 (95% CI, 0.48 to 1.27; two-sided P = .32). The objective response rate was 3% with selumetinib plus dacarbazine and 0% with placebo plus dacarbazine (two-sided P = .36). At 37% maturity (n = 48 deaths), analysis of overall survival gave a hazard ratio of 0.75 (95% CI, 0.39 to 1.46; two-sided P = .40). The most frequently reported adverse events (selumetinib plus dacarbazine v placebo plus dacarbazine) were nausea (62% v 19%), rash (57% v 6%), fatigue (44% v 47%), diarrhea (44% v 22%), and peripheral edema (43% v 6%). Conclusion In patients with metastatic uveal melanoma, the combination of selumetinib plus dacarbazine had a tolerable safety profile but did not significantly improve PFS compared with placebo plus dacarbazine.

Locally Advanced Breast Cancer Treated with Primary Chemotherapy: Comparison between Magnetic Resonance Imaging and Pathologic Evaluation of Residual Disease

Aims and Background

We evaluated the response of locally advanced breast cancer to induction chemotherapy using MRI techniques. The size and vitality of any residual pathologic tissue was quantified by means of morphologic and dynamic analysis. A curve derived from the dynamic parameters shows the uptake intensity with respect to the time elapsed since administration, which is related to vascularization and therefore indirectly reflects the angiogenesis of malignant tissue.

Methods and Study Design

A group of 30 patients were examined with MRI for staging purposes before undergoing treatment and subsequently to assess the response to treatment. Alterations in size and dynamic parameters were closely monitored.

Results

The overall accuracy was 90%, the sensitivity 96%, the specificity 75%, the positive predictive value 92.5% and the negative predictive value 66%. Interestingly, analysis of the dynamic curves made it possible to obtain additional information regarding the angiogenetic activity of the residual tumor.

Conclusions

Evaluation of the response to treatment by means of conventional imaging and clinical examination can be particularly difficult because of the fibrosis induced by cytotoxic drugs or the small volume of residual disease. The additional information supplied by MRI could therefore allow a more conservative surgical approach in selected cases of optimal response to treatment, as well as a much more accurate follow-up. Furthermore, the variation in dynamic parameters according to the vitality of residual disease could in the future become a useful tool for monitoring the effectiveness of anti-angiogenetic drugs.

Localization of the Sentinel Lymph Node in Breast Cancer by Combined Lymphoscintigraphy, Blue DYE and Intraoperative Gamma Probe

Axillary lymph node status represents the most important prognostic factor in patients with operable breast cancer. A severe limitation of this technique is the relatively high rate of false negative sentinel lymph nodes (>5%). We studied 284 patients suffering from breast cancer; 264 had T1 tumors (16 T1a, 37 T1b and 211 T1c), while 20 had T2 tumors. All patients underwent lymphoscintigraphy 18-h before surgery. At surgery, 0.5 mL of patent blue violet was injected subdermally, and the sentinel lymph node (SN) was searched by gamma probe and by the dye method. The surgically isolated SN was processed for intraoperative and delayed examinations.

The SN was successfully identified by the combined radioisotopic procedure and patent blue dye technique in 278/284 cases (97.9%). Analysis of the predictive value of the SN in relation to the status of the axillary lymph nodes was limited to 191 patients undergoing standard axillary dissection irrespective of the SN status. Overall, 63/191 (33%) identified SNs were metastatic, the SN alone being involved in 37/63 (58.7%) patients; a positive axillary status with negative SN was found in 10/73 (13.7%) patients with metastatic involvement. In T1a-T1b patients the SN turned out to be metastatic in 9/53 patients (17.0%). In 7/9 patients the SN was the only site of metastasis, while in 2/9 patients other axillary lymph nodes were found to be metastatic in addition to the SN. None of the 44 patients in whom the SN proved to be non-metastatic showed any metastatic involvement of other axillary lymph nodes.

Our results demonstrate a good predictive value of SN biopsy in patients with breast cancer; the predictive value was excellent in those subjects with nodules smaller than 1 cm.

Mapping the Sentinel Lymph Node in Malignant Melanoma by Blue Dye, Lymphoscintigraphy and Intraoperative Gamma Probe

Eighty-eight consecutive patients (48 men and 40 women; mean age, 58.9 years; range, 16–84 years) with clinically localized cutaneous melanoma involving the trunk, extremities or head and neck underwent lymphatic mapping at our institution. The primary melanoma had a mean thickness of 2.74 mm (range, 0.95 to 9 mm). Patients were divided into two groups: group A (39 patients) underwent only vital blue dye (VBD) mapping, while group B (49 patients) underwent lymphatic mapping with VBD and radio-guided surgery (RGS) combined. In all patients 1-1.5 mL of VBD was injected subdermally around the biopsy scar 10–20 min before surgery. In group B 37 MBq in 150 μL of 99mTc-HSA nanocolloid was additionally injected intradermally 18 h before surgery (3–6 aliquots injected perilesionally). In all lymphatic basins where drainage was noted the sentinel lymph nodes (SNs) were identified and marked with a cutaneous marker. Final identification of the SN was then performed externally by a hand-held gamma probe. After the induction of anesthesia 0.5–1-0 mL of patent blue V dye was injected intradermally with a 25-gauge needle around the site of the primary melanoma. SNs were examined by routine hematoxylin and eosin (H&E) staining and immunohistochemistry. Patients with histologically positive SN(s) underwent standard lymph node dissection (SLND) in the involved lymph node basin.

The SN was identified in 37/39 patients (94.9%) of group A and in 48/49 patients (98.0%) of group B. Blue dye mapping failed to identify the SN in 5 of the 88 patients (5.8%), while the radioisotope method failed in only 1 of 49 patients (2.0%). Similar results were obtained with the combined use of the two probes. The average number of SNs harvested was 1.9 per basin sampled, which does not differ significantly from the numbers reported by other authors114. The SN was histologically positive in 18 patients (20.5%). None of the 12 patients with a Breslow thickness less than 1.5 mm had positive SNs, whereas 18 of the 77 patients (23.4%) with a Breslow index exceeding 1.5 mm showed metastatic SNs with H&E or immunohistochemistry. The latter all underwent SLND of the affected basin. In 10 patients (55.6%) the SN was the only site of tumor invasion; eight patients (44.4%) with positive SNs had one or more metastatic lymph nodes in the draining basin.

Lobular Breast Cancer: How Useful is Breast Magnetic Resonance Imaging?

Rationale and objectives

To review magnetic resonance imaging (MRI) findings in lobular breast carcinoma, the in situ or infiltrating subtype, with special attention to the dynamic curves with the aim to evaluate possible differences with ductal carcinoma.

Methods

In 2 years, 27 patients with lobular and one with tubular carcinoma underwent MRI at the Istituto Nazionale Tumori of Milan.

Results

All lobular carcinomas demonstrated early or late enhancement (100% sensitivity), without significant differences in morphology compared with ductal carcinoma, but frequently with a different shape of the dynamic curves.

Conclusions

Due to its infiltrative growth associated to only limited connective tissue reaction, lobular carcinoma often encounters difficulties in mammographic diagnosis. In contrast, MRI can be very helpful in evaluating the true extension of the disease, especially when breast conservation is considered. Due to a more consistent fibrotic stroma, these lesions sometimes show a delayed enhancement, which suggests that more than one set of subtracted images should be evaluated during MRI analysis.

Self-assembled polyoxometalate-dendrimer structures for selective photocatalysis

We present a novel, self-assembled nanostructure with selective photocatalytic activity formed from anionic polyoxometalate clusters and cationic dendrimers by electrostatic self-assembly. The association of the components in aqueous solution is driven by ionic interaction and steric factors yielding stable aggregates of a defined size with a coil-like structure. The assemblies show high potential for the application in solar-energy conversion systems due to their enhanced and substrate specific photocatalytic activity.

Minimally invasive radio-guided parathyroidectomy on a group of 452 primary hyperparathyroid patients

The aim of this study was to investigate the efficacy of minimally invasive radio-guided parathyroidectomy (MIRP) in primary hyperparathyroid (PHPT) patients. Patients, methods: 452 consecutive PHPT patients were evaluated. Inclusion criteria for MIRP were (a) evidence at scintigraphy of a solitary parathyroid adenoma (PA); (b) a clear sestamibi uptake in the PA; (c) the absence of concomitant thyroid nodules; (d) no history of familial HPT or MEN; (e) no history of previous neck irradiation. Intra-operative protocol consisted of the injection of a low 37 MBq sestamibi dose in the operating suite 10 min before surgery. A hand held 11-mm collimated gamma probe was used. Quick PTH (QPTH) was routinely measured. Results: 344 out of the 452 patients met the inclusion criteria, and MIRP was successfully performed in 321 of them (93.3%). No major intra-operative complication was recorded. MIRP required a mean operative time of 32 min, and a mean hospital stay of 1.2 d. The parathyroid to background ratio (P/B) calculated by the probe was well correlated with the P/B calculated by sestamibi SPECT (r = 0.91; p <0.01), while no significant correlation was found between the probe-calculated P/B and the P/B calculated at planar sestamibi scan. Conclusions: In our experience: a) an accurate preoperative localising imaging protocol based on planar and SPECT sestamibi scan, and neck US is effective in selecting PHPT patients for MIRP, b) the P/B calculated by sestamibi SPECT seems able to predict the probe-calculated P/B more accurately than the P/B calculated at planar scan, c) the low 37 MBq sestamibi dose protocol proved to be a safe and effective approach to perform MIRP.

Pregnancy in CADASIL

OBJECTIVES

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited cerebral small vessel disease caused by NOTCH3 gene mutations. CADASIL women are frequently considered at high risk of systemic vascular events during pregnancy and often prescribed with antithrombotic drugs. This decision is not evidence-based considering the lack of data about pregnancy outcome in CADASIL. We describe our experience on pregnancy in CADASIL patients.

MATERIALS AND METHODS

We reviewed records of 50 CADASIL females followed in our center, and we collected prospective information in six patients for a total of 93 pregnancies.

RESULTS

No woman had the disease onset or suffered from cerebral vascular ischemic events during pregnancy. Sixteen miscarriages (17.2%) were recorded. There were 72 vaginal births, and five cesarean sections. Considering the six patients followed prospectively (for a total of eight pregnancies), data on fetal growth and newborns weight were in line with those from the general population. Considering gestational complications, we recorded mild proteinuria without hypertension in one patient and hyperinsulinemia and pre-eclampsia in another affected by a known nephropathy. Antithrombotic drugs were used in three patients, in one for an unrelated coexisting prothrombotic condition.

CONCLUSIONS

CADASIL does not seem to be associated with an unfavorable outcome of pregnancy either for women and fetuses. Patients and treating physicians should be reassured that pregnancy can be safely initiated in CADASIL, as there is no evidence to support a specific preventive antithrombotic treatment during pregnancy in CADASIL. Larger studies are needed to definitively confirm these conclusions.