White Embolus-induced Basilar Artery Occlusion Due to Pulmonary Vein Invasion of a Metastasis of a Malignant Melanoma

An 80-year-old woman presented with impaired consciousness after malignant melanoma resection. Magnetic resonance angiography showed basilar artery occlusion, which was subjected to mechanical thrombectomy for recanalization. A pathological analysis of the retrieved embolus revealed that it was derived from a metastasis of malignant melanoma. Contrast-enhanced chest computed tomography showed multiple pulmonary metastases, one of which was in the right upper lobe and invaded the pulmonary vein. To our knowledge, this is the first case of white embolus-induced cerebral embolism due to pulmonary vein invasion of a metastasis of a pathologically diagnosed malignant melanoma.

Factors related to white thrombi in acute ischemic stroke in cancer patients

OBJECTIVES

Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients.

METHODS

Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups.

RESULTS

There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 [95% confidence interval 1.71-368.99], p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity).

CONCLUSIONS

In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.

Disconnection of a stent retriever's pushwire caught by an accordion-like deformed aspiration catheter during mechanical thrombectomy: illustrative case

BACKGROUND

In mechanical thrombectomy for acute large vessel occlusion, a combined technique of using both a stent retriever and an aspiration catheter has been widely used. The authors report a case in which a stent retriever's pushwire and a microcatheter were caught and disconnected by an accordion-like deformed aspiration catheter.

OBSERVATIONS

A 74-year-old man underwent mechanical thrombectomy for a left M1 occlusion. A stent retriever was deployed from the left M2 to the left distal M1, and an aspiration catheter was advanced to the left distal M1. When the stent retriever and microcatheter were pulled into the aspiration catheter at the distal M1 without releasing the deflection, traction resistance of the stent retriever occurred, and the aspiration catheter contracted and deformed like an accordion distal to the tip of the guiding catheter. The stent retriever's pushwire and the microcatheter were caught and disconnected.

LESSONS

When a stent retriever is pulled into a flexible aspiration catheter in a case with vascular tortuosity, it may be caught by an accordion-like deformed aspiration catheter and disconnected. It is necessary to release the deflection of the aspiration catheter once traction resistance of the stent retriever and deflection of the aspiration catheter occur.

Reduction of noise induced by power supply lines using phase-locked loop

An experimental implementation for the reduction of power-line noise in delicate signal detection is presented. This implementation improves the signal-to-noise ratio without limiting the bandwidth of the measurement. A sinusoidal wave and its harmonics, both synchronized with the frequency of the power line, are used to cancel out the power supply noise induced in the measurement signal. The wave and the harmonics are generated via a phase-locked loop implementation. Their amplitude and phase are adjusted, and then they are added to the measurement signal using a series of operational amplifiers to compensate for the noise. Although we applied this method to the particular case of scanning tunneling microscopy measurements, considerably improving the image quality, our implementation can be applied to other measurement systems for which noise from the power lines can compromise the signal detection.

Clinical features and long-term outcomes of symptomatic low-grade carotid stenosis

OBJECTIVE

In symptomatic low-grade stenosis, most of the reports did not clarify the long-term outcome. This study aims to clarify the clinical features and long-term outcomes of symptomatic low-grade stenosis cases.

MATERIALS AND METHODS

We included 123 symptomatic patients with low-grade (<50%) carotid stenosis. The relative plaque signal intensity (rSI) and expansive remodeling rate (ERR) were measured using carotid magnetic resonance imaging (MRI). Antiplatelet therapy and treatment for atherosclerosis risk factors were administered in all cases. Carotid endarterectomy (CEA) was performed when ischemic symptoms appeared, or the percent stenosis progressed despite medical treatment.

RESULTS

The mean percent stenosis, rSI, and ERR on admission were 22.3, 1.70, and 2.01, respectively. The mean volume of the hyperintense plaque on carotid MRI was 641.4± 540 mm3. Sixty percent of cases involved intraplaque hemorrhage and expansive remodeling. During a mean follow-up of 52 months, recurrence of ischemic events was confirmed in 45 cases (36.6%). Of the 67 cases performed follow-up MRI, 34 cases (50%) had an increased volume of T1-hyperintense plaque. CEA or carotid artery stenting was performed in 49 cases. During a mean follow-up of 57.8 months after CEA, two cases of death (fatal intracerebral hemorrhage and asphyxia) and one case of brain stem lacunar infarction were observed, but ipsilateral ischemic events were not.

CONCLUSION

Most of the symptomatic patients with low-grade stenosis had both intraplaque hemorrhage and expansive remodeling and presented a high risk of recurrence and stenosis progression. CEA may have preventive effects against ischemic events in low-grade stenosis.

P-199 Effect of the area of oocyte perivitelline space on the fertilization and embryo development following intracytoplasmic sperm injection

Study question

Does the area of oocyte perivitelline space have an effect on fertilization and embryo development following intracytoplasmic sperm injection?

Summary answer

The area of oocyte perivitelline space has not an effect on the fertilization but the embryo development following intracytoplasmic sperm injection.

What is known already

Oocyte perivitelline space has a lot of variation at intracytoplasmic sperm injection (ICSI). Some researchers reported that the characteristics of perivitelline space (large or small) affect embryo development, pregnancy, and implantation. However, these studies did not accurately calculate the area of perivitelline space. Therefore, little information is available on the effect of the area of oocyte perivitelline space on fertilization and embryo development following ICSI. The purpose of this study was to calculate and classify the area of oocyte perivitelline space and investigate the effect of the area of perivitelline space on fertilization and embryo development following ICSI.

Study design, size, duration

1. We retrospectively investigated 634 mature oocytes that were conducted ICSI between January 2021 and December 2021. The area of each oocyte perivitelline space was defined from between the area of circle calculated from the inner layer of zona pellucida and cytoplasm and divided into 3 groups (-9%, 10-19%, 20%-).

2. We retrospectively calculated the diameter of an inner layer of zona pellucida and cytoplasm and compared it with the 3 groups (-9%, 10-19%, 20%-).

Participants/materials, setting, methods

1. The fertilization, survival, good quality day-3 embryo, blastocyst, good quality blastocyst rates following ICSI were compared with the 3 groups (-9%, 10-19%, 20%-).

2. The average diameter of an inner layer of zona pellucida and cytoplasm of each oocyte for the 3 groups (-9%, 10-19%, 20%-) were compared.

The data were analyzed by Fisher’s exact test, residual analysis, one-way ANOVA test, with Bonferroni correction as appropriate to determine the statistical differences among groups.

Main results and the role of chance

1. The survival rates of perivitelline space -9%, 10-19%, 20%- groups were 100% (109/109), 96% (363/378), 94% (138/147), the fertilization rates were 89% (97/109), 88% (331/378), 86% (127/147), the good quality day-3 embryo rates were 56% (54/97), 70% (232/331), 70% (89/127) respectively. No significant difference was observed between these comparison items. The blastocyst rates of perivitelline space -9%, 10-19%, 20%- groups were 51% (47/92), 69% (222/321), 82% (93/114), the good quality blastocyst rates were 22% (20/92), 40% (129/321), 52% (59/114) respectively. The blastocyst and good quality blastocyst rates of perivitelline space -9% group showed significantly lower results. On the other hand, the blastocyst and good quality blastocyst rates of perivitelline space 20%- group showed significantly higher results.

2. The average diameter of an inner layer of zona pellucida of perivitelline space -9%, 10-19%, 20%- groups were 125 ± 4 µm, 129 ± 5 µm, 136 ± 6 µm, the average diameter of the cytoplasm of perivitelline space were 121 ± 4 µm, 119 ± 4 µm, 118 ± 4 µm respectively. Significant differences were observed in all pairs of groups of the average diameter of an inner layer of zona pellucida and cytoplasm.

Limitations, reasons for caution

The area of oocyte perivitelline space was calculated at only one plane.

Wider implications of the findings

Oocytes with narrow perivitelline space might have a wide region of adhesive between the cytoplasm surface and an inner layer of the zona pellucida which resulted in a smaller diameter of the zona pellucida and lower blastocyst rate by forming cytoplasmic fragments (Yumoto K et al. JARG. 2020 ;37(6):1349-1354.).

Trial registration number

Not Applicable

Whole-genome sequencing analysis of an atypical teratoid/rhabdoid tumor in a patient with Phelan-McDermid syndrome: a case report and systematic review

Atypical teratoid/rhabdoid tumor (AT/RT) is a rare pediatric brain tumor with abnormalities in SMARCB1 located in 22q11.2. We report a case of AT/RT associated with Phelan-McDermid syndrome (PMS) characterized by congenital developmental disorder, mental retardation, and ring chromosome 22 with 22q13.3-qter depletion, for which we performed whole-genome sequencing (WGS). A 4-year-old girl with a developmental disability was referred to our hospital due to dysphoria. Brain magnetic resonance imaging showed a 5-cm well-demarcated mass that extended bilaterally in the frontal lobes. G-banding was performed preoperatively due to a history of developmental retardation. Ring chromosome 22 and deletion of 22q13.3-qter were observed, and she was diagnosed with PMS. She underwent gross total resection of the tumor, and the pathological diagnosis was AT/RT. WGS showed somatic SMARCB1 mutation (p.R201X) and somatic loss of the entire chromosome 22 in the tumor, but not in the blood sample. WGS confirmed previously unreported BRCA2 mutations, 6q loss, and 14q acquisition during tumor progression, but no other significant findings associated with tumor progression. The present case is discussed with reference to a systematic review of previous reports of AT/RT associated with PMS. PMS patients with ring chromosome 22 should be carefully followed up for AT/RT occurrence.

Cerebral Amyloidoma Accompanied by Sjögren's Syndrome: A Case Report and Literature Review

We present a 69-year-old woman with colorectal cancer and a left frontal lobe tumor that was diagnosed as a cerebral amyloidoma after surgical resection. Further postoperative systemic evaluation revealed another amyloidoma in her hip as well as Sjögren's syndrome. Systemic amyloidosis was not present. To the best of our knowledge, this is the first case of cerebral amyloidoma presenting as one of the multiple localized amyloidomas accompanied by Sjögren's syndrome. We also present a systematic review of 65 cerebral amyloidoma cases reported in the literature over the past 40 years and discuss patient characteristics and pathological and imaging findings associated with prognosis.

AB0391 LOW SERUM COMPLEMENT C3 LEVEL AS A RISK FACTOR FOR RELAPSE OF ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS: A RETROSPECTIVE COHORT STUDY

Background:

The alternative pathway of complement activation has recently been recognized as a key pathogenic event in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Some previous studies have reported that low serum complement C3 level in AAV patients is associated with more severe renal disease, worse renal prognosis, or higher mortality. However, the correlation between low serum C3 level and AAV relapse remains unclear.

Objectives:

To analyze the clinical characteristics and outcomes of AAV patients with low serum C3 levels at the time of diagnosis.

Methods:

We conducted a retrospective observational cohort study including 83 consecutive patients diagnosed with AAV in our hospital from January 1999 to December 2020. Serum C3 levels were measured at diagnosis. AAV included microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), and eosinophilic granulomatosis with polyangiitis (EGPA); patients with ANCA-negative AAV were excluded. Patients were divided into low- and high-C3 groups (C3 < 100 and ≥ 100 mg/dL, respectively). We compared the clinical characteristics, and relapse-free and overall survival rates, of the two groups, and identified predictors of AAV relapse.

Results:

Of the 83 patients (MPA, n = 61; GPA, n = 18; EGPA, n = 4), 20 (24%) were in the low-C3 group. We found no significant group difference in sex, body mass index, disease type, ANCA subtype, Birmingham Vasculitis Activity Score (BVAS), or treatment. The low-C3 group patients were older (p=0.01), and had a higher Five Factor Score (FFS) (p=0.01) and a lower remission rate (p=0.02), than the high-C3 group. The generalized Wilcoxon test revealed that the relapse-free survival time was significantly shorter in the low-C3 group (29 months; 95% confidence interval [CI]: 15–49) than in the high-C3 group (82 months; 95% CI: 61–NA; p=0.01) (Figure 1A). The overall survival was also shorter in the low-C3 group (83 months; 95% CI: 8-121) than in the high-C3 group (112 months; 95% CI: 77-NA; p=0.03) (Figure 1B). In the Cox proportional hazards model, a low C3 level (< 100 mg/dL) (hazard ratio [HR], 3.01; 95% CI: 1.29–7.04], p=0.01) and GPA (HR, 3.04; 95% CI: 1.32–7.01; p=0.01) were independent predictors of AAV relapse.

Figure 1.

Kaplan-Meier estimates of the relapse-free (A) and overall (B) survival rates of AAV patients by baseline serum C3 levels. Eight patients who did not show remission were excluded in the relapse-free survival analysis. Black line: high-C3 group (≥ 100 mg/dL); red line: low-C3 group (< 100 mg/dL).

Conclusion:

AAV patients with low C3 levels at diagnosis were at higher risk of relapse. Larger prospective studies are required to confirm these findings.

Disclosure of Interests:

None declared

Mixed germ cell tumor infiltrating the pineal gland without elevated tumor markers: illustrative case

BACKGROUND

Tumors in the pineal region consist of various histological types, and correct diagnosis from biopsy specimens is sometimes difficult. The authors report the case of a patient with a mixed germ cell tumor infiltrating into the pineal gland despite showing no elevation of tumor markers.

OBSERVATIONS

An 18-year-old man complained of headache and nausea and showed disturbance of consciousness. Magnetic resonance imaging showed hydrocephalus associated with a cystic pineal tumor. The patient underwent tumor biopsy followed by endoscopic third ventriculostomy for hydrocephalus in a local hospital. A pineocytoma was diagnosed, and the patient was referred to the authors' hospital for treatment. Concentrations of placental alkaline phosphatase, alpha-fetoprotein (AFP), and beta-human chorionic gonadotropin in cerebrospinal fluid were not elevated. However, the authors' review of the tumor specimen revealed some immature cells infiltrating the pineal gland. These cells were positive for AFP, Sal-like protein 4, and octamer-binding transcription factor 3/4; and the diagnosis was changed to mixed germ cell tumor. Chemoradiotherapy was initiated, followed by surgical removal of the residual tumor.

LESSONS

Careful examination of all tumor specimens and immunohistochemical analyses are important for accurate diagnosis of pineal tumors.

SAT0040 RISK FACTORS FOR DEVELOPING AND MORTALITY FOR ACUTE EXACERBATION OF RHEUMATOID ARTHRITIS-ASSOCIATED INTERSTITIAL LUNG DISEASE

Background:

Among collagen vascular diseases, rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is the most commonly associated with ILD with acute exacerbation (AE) [1]. One study reported that ILD diagnosis at an older age, the usual interstitial pneumonia (UIP) pattern on high-resolution computed tomography, and methotrexate (MTX) use were associated with AE in patients with RA-ILD [2]. However, because these studies included few patients, the risk factors and prognosis of AE in patients with RA-ILD remain unclear. Therefore, this study examined the characteristics of RA-ILD patients with AE, and the variables associated with mortality due to AE of RA-ILD.

Objectives:

To investigate the risk factors for AE and mortality of RA-ILD.

Methods:

We retrospectively collected the clinical data of 165 RA-ILD patients admitted to our hospital between July 2010 and October 2019. We compared clinical characteristics between patients who developed AE (AE group) and those who did not (non-AE group), and identified the variables significantly associated with AE occurrence. We also compared the admission characteristics of those who survived (survivor group) and those who died (non-survivor group) after admission for AE. AE was defined using previously proposed criteria [3], which were modified slightly for application to RA-ILD.

Results:

The mean patient age was 73.6 ± 9.7 years and 97 (71.9%) patients were female. Thirty (22.2%) patients developed AE, of whom thirteen (43.3%) died (mean follow-up, 64.9 months). In univariate analyses UIP pattern and MTX were not associated with AE. However, in multivariate analyses, UIP pattern was associated with AE (OR 2.68, 95% CI 1.10–6.52,p=0.03). Median age (70vs. 80 years,p=0.003), non-use of MTX (70.6%vs. 23.1%,p=0.025), and C reactive protein level (median 9.38vs. 18.12 mg/dL,p=0.02) on admission were significantly higher in patients who died of AE. In the Cox proportional hazard model, UIP pattern (HR 4.67, 95% CI 1.02–21.5,p=0.048) and non-use of MTX (HR 0.16, 95% CI 0.04–0.72,p=0.016) were associated with death.

Conclusion:

Our data suggest that the UIP pattern is related to AE, and non-use of MTX and UIP pattern are related to death due to AE of RA-ILD.

References:

[1] Suda T, Kaida Y, Nakamura Y et al. Acute exacerbation of interstitial pneumonia associated with collagen vascular diseases.Respir Med2009;103:846-53.

[2] Hozumi H, Nakamura Y, Johkoh T et al. Acute exacerbation in rheumatoid arthritis-associated interstitial lung disease: a retrospective case control study.BMJ Open2013;3:e003132.

[3] Collard HR, Moore BB, Flaherty KR et al. Idiopathic pulmonary fibrosis clinical research network investigators. Acute exacerbations of idiopathic pulmonary fibrosis.Am J Respir Crit Care Med2007;176:636-43.

Disclosure of Interests:

None declared

Developing Transposable Element Marker System for Molecular Breeding

Transposable element (TE) marker system was developed considering the useful properties of the transposable elements such as their large number in the animal and plant genomes, high rate of insertion polymorphism, and ease of detection. Various methods have been employed for developing a large number of TE markers in several crop plants for genomics studies. Here we describe some of these methods including the recent whole genome search. We also review the application of TE markers in molecular breeding.

Delayed lupus nephritis in the course of systemic lupus erythematosus is associated with a poorer treatment response: a multicentre, retrospective cohort study in Japan

Objective

The objective of this study was to investigate possible differences in treatment responses between two categories for the onset of lupus nephritis.

Methods

We performed a multicentre, retrospective cohort study of class III–V lupus nephritis patients diagnosed between 1997 and 2014. The renal responses to initial induction therapy were compared between patients who developed lupus nephritis within one year from diagnosis of systemic lupus erythematosus (early (E-) LN) and the remainder (delayed (D-) LN) using the Kaplan–Meier method. We determined the predictors of renal response as well as renal flares and long-term renal outcomes using multivariate Cox regression analyses.

Results

A total of 107 E-LN and 70 D-LN patients were followed up for a median of 10.2 years. Log-rank tests showed a lower cumulative incidence of complete response in D-LN compared with E-LN patients. Multivariate analysis identified D-LN (hazard ratio (HR) 0.48, 95% confidence interval (CI) 0.33–0.70), nephrotic syndrome at baseline, and a chronicity index greater than 2 as negative predictors of complete response. D-LN patients were more likely to experience renal flares. D-LN (HR 2.54, 95% CI 1.10–5.83) and decreased renal function were significant predictors of chronic kidney disease at baseline.

Conclusion

D-LN was a predictor of poorer treatment outcomes, in addition to renal histology and severity of nephritis at lupus nephritis onset.

Association of preoperative inflammation-based prognostic score with survival in patients undergoing salvage esophagectomy

Salvage esophagectomy (SALV) is potentially beneficial for patients with residual or relapsed esophageal carcinoma after definitive chemoradiotherapy (dCRT), although preoperatively identifying good candidates for SALV remains difficult. We investigated the prognostic impacts of inflammatory and nutritional status in patients undergoing SALV after dCRT. Forty-seven SALV patients were retrospectively reviewed, of whom 46 (98%) had squamous cell carcinoma and 1 (2%) adenocarcinoma. Possible prognostic factors included patients' demographic data, physical status, blood chemistry profiles, and clinical/pathological tumor features. The Glasgow prognostic score (GPS) was derived from preoperative C-reactive protein (CRP) and albumin values. Thirty (64%), 11 (23%), and 6 (13%) patients were classified into the GPS 0, 1, and 2, respectively, groups. None of the possible prognostic factors showed significant correlations with GPS. Patients with GPS 0 had better outcomes than those with GPS 1 or GPS 2 (Median survivals: 37.8, 15.9, and 5.1 months, respectively, P < 0.001). In the multivariable Cox proportional hazards model, GPS 1 (HR 5.62, 95% CI 1.94-16.4, P = 0.002), GPS 2 (HR 9.10, 95% CI 2.60-31.8, P < 0.001), R1/2 resection (HR 16.3, 95% CI 3.62-86.7, P < 0.001) and incomplete response to dCRT (HR 3.53, 95% CI 1.12-12.5, P = 0.03) were all independent risk factors for a poor outcome. Preoperative GPS is potentially useful for predicting outcomes in esophageal cancer patients undergoing SALV.

Presentation of oropharyngeal dysphagia and rehabilitative intervention following esophagectomy: a systematic review

No study has systematically reviewed the evidence on presentation of oropharyngeal dysphagia and swallowing rehabilitation following esophagectomy. The purposes of this systematic review are to 1) qualitatively synthesize the current findings on oropharyngeal swallowing abnormalities identified by instrumental swallowing evaluations, 2) describe the reported health-related outcomes in relation to swallowing abnormality following esophagectomy, and 3) examine the efficacy of reported rehabilitative interventions for oropharyngeal dysphagia in patients who underwent esophagectomy. Publications were searched using five electronic databases. No language or publication date restrictions were imposed. Two authors performed a blind review for published or unpublished studies that reported swallowing biomechanics and dysphagic symptoms using instrumental evaluation of swallowing, specifically the videofluoroscopic swallowing study and fiberoptic endoscopic evaluation of swallowing, and/or health-related outcomes in relation to swallowing abnormalities, and/or therapeutic interventions for oropharyngeal dysphagia following esophagectomy. Twelve studies out of 2,193 studies including 458 patients met the inclusion criteria. Reported abnormal swallowing biomechanics included vocal fold immobility, delayed onset of swallowing, reduced hyolaryngeal elevation, and reduced opening of the upper esophageal sphincter. Aspiration (0-81%) and pharyngeal residue (22-100%) were prevalent. Those abnormal swallowing biomechanics and swallowing symptoms were commonly reported following both transhiatal and transthoracic esophagectomy. Pneumonia presented in 5-25% of the study patients. One quasi-experimental study examined the effectiveness of swallowing exercises for postoperative oropharyngeal dysphagia; three case series reported a benefit of the chin-tuck maneuver in reducing aspiration and residue. This review revealed distinct swallowing impairments and increased pneumonia risks following esophagectomy. This review also found that evidence on the efficacy of therapeutic interventions was limited. Future studies are warranted to develop effective rehabilitative interventions for postesophagectomy patients with oropharyngeal dysphagia.

Changes in resting-state brain networks after cognitive-behavioral therapy for chronic pain

BACKGROUND

Cognitive-behavioral therapy (CBT) is thought to be useful for chronic pain, with the pathology of the latter being closely associated with cognitive-emotional components. However, there are few resting-state functional magnetic resonance imaging (R-fMRI) studies. We used the independent component analysis method to examine neural changes after CBT and to assess whether brain regions predict treatment response.

METHODS

We performed R-fMRI on a group of 29 chronic pain (somatoform pain disorder) patients and 30 age-matched healthy controls (T1). Patients were enrolled in a weekly 12-session group CBT (T2). We assessed selected regions of interest that exhibited differences in intrinsic connectivity network (ICN) connectivity strength between the patients and controls at T1, and compared T1 and T2. We also examined the correlations between treatment effects and rs-fMRI data.

RESULTS

Abnormal ICN connectivity of the orbitofrontal cortex (OFC) and inferior parietal lobule within the dorsal attention network (DAN) and of the paracentral lobule within the sensorimotor network in patients with chronic pain normalized after CBT. Higher ICN connectivity strength in the OFC indicated greater improvements in pain intensity. Furthermore, ICN connectivity strength in the dorsal posterior cingulate cortex (PCC) within the DAN at T1 was negatively correlated with CBT-related clinical improvements.

CONCLUSIONS

We conclude that the OFC is crucial for CBT-related improvement of pain intensity, and that the dorsal PCC activation at pretreatment also plays an important role in improvement of clinical symptoms via CBT.

Abstract P5-21-32: AZD5363 in combination with fulvestrant in AKT1-mutant ER-positive metastatic breast cancer

Background: E17K is the most common activating AKT1 mutation and was shown to be a therapeutic target in this multipart Phase 1 study of AZD5363 (NCT01226316), an oral and selective pan-AKT kinase inhibitor, in patients (pts) with AKT1-mutant (AKT1m) advanced solid tumors. In heavily pretreated AKT1m (E17K) ER+ metastatic breast cancer (MBC) pts, monotherapy achieved an objective response rate (ORR) of 20% and a median progression-free survival of 5.5 months (95% CI, 2.9−6.9). Suppression of PI3K-AKT signaling results in induction of ER-dependent transcription, potentially limiting the response to single-agent PI3K/AKT inhibitors. We explored the hypothesis that simultaneous inhibition of AKT and ER signaling would enhance antitumor efficacy in AKT1m ER+ MBC.

Methods: In an expansion of this study, we administered oral AZD5363 400 mg twice daily, 4 days on 3 days off, and fulvestrant 500 mg, to AKT1m (detected in tumor tissue by local screening and/or plasma BEAMing) ER+ HER2– MBC pts, enrolled into a fulvestrant-naïve (FN) or fulvestrant-resistant (FR) cohort (max 24 pts/cohort). Key objectives included safety and efficacy by RECIST v1.1. We report results of a planned interim analysis conducted when 12 pts/cohort reached maturity for assessment of 24-week clinical benefit rate (CBR), defined as the percentage of responders plus those with stable disease (SD) ≥24 weeks.Data cut-off occurred in June 2017.

Results: At the time of analysis, 24 AKT1m pts (23 E17K, 1 E40K) had received treatment. FN had more visceral disease (83.3% vs 66.7%) and ER+/PR– status (25% vs 8.3%) than FR. Median number of prior anticancer regimens was 4.5 (range 1–9) and 6 (2–11) in FN and FR, respectively, with more chemotherapy (CT) and less hormone therapy (HT) exposure in FN vs FR [3 (0–5) vs 2 (0–6) and 2 (0–4) vs 4 (2–6) prior CT and HT, respectively]. Prior palbociclib was received by 1 (8.3%) and 4 (33.3%) pts in FN and FR, respectively. Clinical efficacy is detailed below; CBR was 33% and 42% in FN and FR, respectively (Table 1). There was 1 unconfirmed partial response in patients treated with prior palbociclib and 3 SD. At data cut-off, 18 pts had discontinued treatment: progressive disease, n=12; adverse events (AEs), n=2; other reasons, n=4. AEs were observed in all 24 pts, most commonly diarrhea (71%), nausea (63%), vomiting and decreased appetite (29%). Grade ≥3 AEs occurred in 13 (54%) pts, most frequently maculopapular rash (n=3), nausea, hyperglycemia and back pain (all n=2). Dose reduction due to AEs occurred in 3 pts.

Table 1. Clinical efficacy FNFREligible for interim data cut-off, n1212ORR, n (%)2 (17)4 (33)CBR, n (%)4 (33)5 (42)Confirmed response (complete/partial response), n (%)2 (17)4 (33)SD ≥24 weeks, n (%)2 (17)1 (8)

Conclusions: AZD5363 plus fulvestrant is clinically active in AKT1m ER+ MBC pts, including in pts with demonstrated prior resistance to fulvestrant. Comparatively lower efficacy was observed in the FN cohort; factors that may have potentially contributed (eg disease characteristics) will be explored. cfDNA and genomic data will also be presented.

Citation Format: Smyth LM, Oliveira M, Ciruelos E, Tamura K, El-Khoueiry A, Mita A, You B, Renouf DJ, Sablin M-P, Lluch A, Mayer IA, Bando H, Yamashita H, Ambrose H, de Bruin E, Carr TH, Corcoran C, Foxley A, Lindemann JPO, Maudsley R, Pass M, Rutkowski A, Schiavon G, Banerji U, Scaltriti M, Taylor BS, Chandarlapaty S, Baselga J, Hyman DM. AZD5363 in combination with fulvestrant in AKT1-mutant ER-positive metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-32.

Abstract P5-21-05: Withdrawn

This abstract was withdrawn by the authors.

Abstract P4-08-07: PIK3CA mutation, reduced AKT serine 473 phosphorylation, and increased ERα serine 167 phosphorylation are positive prognostic indicators in postmenopausal estrogen receptor-positive, HER2-negative early breast cancer

Background: Endocrine therapy is the most important treatment option for women with estrogen receptor (ER)-positive breast cancer. We recently reported that approximately two-thirds of patients who relapsed within 5 years had received anthracyclins and/or taxanes as adjuvant or neoadjuvant chemotherapy in addition to adjuvant endocrine therapy. New strategies, such as signal transduction inhibitors together with endocrine therapy are required to improve survival. PIK3CA mutations are detected in almost 40% of early ER-positive breast cancers, and are therefore the most frequent genetic alterations in this subtype. PIK3CA mutation status is reported to affect activation of AKT and ERα. Moreover, recent studies demonstrate that patients had a better prognosis when tumors expressed ER, androgen receptor (AR), and vitamin D receptor (VDR).

Methods: Expression of AR and VDR, phosphorylation of AKT serine (Ser) 473 (AKT phospho-Ser473) and ERα Ser167 (ERα phospho-Ser167) were examined by immunohistochemistry in ER-positive, HER2-negative early breast cancer tissues. Seventeen mutations in exons 1, 4, 7, 9, and 20 of the PIK3CA gene were detected in genomic DNA extracted from formalin-fixed paraffin-embedded tumor blocks. Correlations between these biological markers and clinicopathological factors and prognosis were analyzed separately in pre- and postmenopausal women.

Results: Levels of AKT phospho-Ser473 were significantly higher in premenopausal women (n = 62) than in postmenopausal women (n = 152) (P &lt; 0.0001 and P = 0.014, respectively). In contrast, expression levels of AR were significantly higher in postmenopausal women than in premenopausal women (P &lt; 0.0001). In premenopausal women, 26 tumors (43%) had a single mutation of PIK3CA gene, and 3 tumors (5%) had mutations at two sites. In postmenopausal women, 64 tumors (44%) had a single PIK3CA mutation, 6 tumors (4%) had mutations at two sites, and one tumor (1%) had mutations at three sites. In premenopausal women, wild type PIK3CA was associated with smaller tumor size, higher ER expression levels, and lower AR expression levels when compared with women in the same cohort with PIK3CA mutant tumors. In postmenopausal women, patients with PIK3CA wild-type tumors had higher Ki67 labeling index, higher AKT phospho-Ser473, and lower ERα phospho-Ser167 when compared to patients with PIK3CA mutant tumors. Postmenopausal women with PIK3CA wild-type tumors had significantly worse disease-free survival than patients with PIK3CA mutant tumors (P = 0.007). In contrast, PIK3CA mutation status was not correlated with survival in premenopausal women. Low levels of AKT phospho-Ser473 and high levels of ERα phospho-Ser167 were strongly associated with increased disease-free survival in postmenopausal women (P = 0.016 and P = 0.0016, respectively).

Conclusion: ERα activation, in addition to PIK3CA mutation, may be biomarkers for highly endocrine-responsive tumors. This would facilitate the selection of postmenopausal ER-positive breast cancer patients who are likely to benefit from endocrine therapy alone from those who are not.

Citation Format: Ishida N, Hatanaka Y, Baba M, Hagio K, Okada H, Hatanaka KC, Matsuno Y, Yamashita H. PIK3CA mutation, reduced AKT serine 473 phosphorylation, and increased ERα serine 167 phosphorylation are positive prognostic indicators in postmenopausal estrogen receptor-positive, HER2-negative early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-08-07.