Circulating tumor DNA association with residual cancer burden after neoadjuvant chemotherapy in triple-negative breast cancer in TBCRC 030

BACKGROUND

We aimed to examine circulating tumor DNA (ctDNA) and its association with residual cancer burden (RCB) using an ultrasensitive assay in patients with triple-negative breast cancer (TNBC) receiving neoadjuvant chemotherapy.

PATIENTS AND METHODS

We identified responders (RCB 0/1) and matched non-responders (RCB 2/3) from the phase II TBCRC 030 prospective study of neoadjuvant paclitaxel versus cisplatin in TNBC. We collected plasma samples at baseline, 3 weeks and 12 weeks (end of therapy). We created personalized ctDNA assays utilizing MAESTRO mutation enrichment sequencing. We explored associations between ctDNA and RCB status and disease recurrence.

RESULTS

Of 139 patients, 68 had complete samples and no additional neoadjuvant chemotherapy. Twenty-two were responders and 19 of those had sufficient tissue for whole-genome sequencing. We identified an additional 19 non-responders for a matched case-control analysis of 38 patients using a MAESTRO ctDNA assay tracking 319-1000 variants (median 1000 variants) to 114 plasma samples from 3 timepoints. Overall, ctDNA positivity was 100% at baseline, 79% at week 3 and 55% at week 12. Median tumor fraction (TFx) was 3.7 × 10-4 (range 7.9 × 10-7-4.9 × 10-1). TFx decreased 285-fold from baseline to week 3 in responders and 24-fold in non-responders. Week 12 ctDNA clearance correlated with RCB: clearance was observed in 10 of 11 patients with RCB 0, 3 of 8 with RCB 1, 4 of 15 with RCB 2 and 0 of 4 with RCB 3. Among six patients with known recurrence, five had persistent ctDNA at week 12.

CONCLUSIONS

Neoadjuvant chemotherapy for TNBC reduced ctDNA TFx by 285-fold in responders and 24-fold in non-responders. In 58% (22/38) of patients, ctDNA TFx dropped below the detection level of a commercially available test, emphasizing the need for sensitive tests. Additional studies will determine whether ctDNA-guided approaches can improve outcomes.

A Phase II Study Evaluating the Safety and Efficacy of Sunitinib Malate in Combination With Weekly Paclitaxel Followed by Doxorubicin and Daily Oral Cyclophosphamide Plus G-CSF as Neoadjuvant Chemotherapy for Locally Advanced or Inflammatory Breast Cancer

INTRODUCTION

Neoadjuvant chemotherapy is standard treatment for locally advanced breast cancer (LABC) or inflammatory breast cancer (IBC). We hypothesized that adding sunitinib, a tyrosine kinase inhibitor with antitumor and antiangiogenic activity, to an anthracycline and taxane regimen would improve pathologic complete response (pCR) rates to a prespecified endpoint of 45% in patients with HER2-negative LABC or IBC.

METHODS

We conducted a multicenter, phase II trial of neoadjuvant sunitinib with paclitaxel (S+T) followed by doxorubicin and cyclophosphamide plus G-CSF for patients with HER2-negative LABC or IBC. Patients received sunitinib 25 mg PO daily with paclitaxel 80 mg/m² IV weekly ×12 followed by doxorubicin 24 mg/m² IV weekly + cyclophosphamide 60 mg/m² PO daily with G-CSF support. Response was evaluated using pCR in the breast and the CPS + EG score (clinical-pathologic scoring + estrogen receptor [ER] and grade).

RESULTS

Seventy patients enrolled, and 66 were evaluable for efficacy. Eighteen patients (27%) had pCR in the breast (10 had ER⁺ disease and 8 had triple-negative disease). When defining response as pCR and/or CPS + EG score ≤2, 31 (47%) were responders. In pateints with ER positive disease, 23 (64%) were responders. The most common toxicities were cytopenias and fatigue.

CONCLUSIONS

Neoadjuvant S+T followed by AC+G-CSF was safe and tolerable in LABC and IBC. The study did not meet the prespecified endpoint for pCR; however, 47% were responders using pCR and/or CPS + EG score ≤2. ER positive patients had the highest response rate (64%). The addition of sunitinib to neoadjuvant chemotherapy may provide promising incremental benefit for patients with ER positive LABC.

TBCRC 030: a phase II study of preoperative cisplatin versus paclitaxel in triple-negative breast cancer: evaluating the homologous recombination deficiency (HRD) biomarker

BACKGROUND

Cisplatin and paclitaxel are active in triple-negative breast cancer (TNBC). Despite different mechanisms of action, effective predictive biomarkers to preferentially inform drug selection have not been identified. The homologous recombination deficiency (HRD) assay (Myriad Genetics, Inc.) detects impaired double-strand DNA break repair and may identify patients with BRCA1/2-proficient tumors that are sensitive to DNA-targeting therapy. The primary objective of TBCRC 030 was to detect an association of HRD with pathologic response [residual cancer burden (RCB)-0/1] to single-agent cisplatin or paclitaxel.

PATIENTS AND METHODS

This prospective phase II study enrolled patients with germline BRCA1/2 wild-type/unknown stage I-III TNBC in a 12-week randomized study of preoperative cisplatin or paclitaxel. The HRD assay was carried out on baseline tissue; positive HRD was defined as a score ≥33. Crossover to an alternative chemotherapy was offered if there was inadequate response.

RESULTS

One hundred and thirty-nine patients were evaluable for response, including 88 (63.3%) who had surgery at 12 weeks and 51 (36.7%) who crossed over to an alternative provider-selected preoperative chemotherapy regimen due to inadequate clinical response. HRD results were available for 104 tumors (74.8%) and 74 (71.1%) were HRD positive. The RCB-0/1 rate was 26.4% with cisplatin and 22.3% with paclitaxel. No significant association was observed between HRD score and RCB response to either cisplatin [odds ratio (OR) for RCB-0/1 if HRD positive 2.22 (95% CI: 0.39-23.68)] or paclitaxel [OR for RCB-0/1 if HRD positive 0.90 (95% CI: 0.19-4.95)]. There was no evidence of an interaction between HRD and pathologic response to chemotherapy.

CONCLUSIONS

In this prospective preoperative trial in TNBC, HRD was not predictive of pathologic response. Tumors were similarly responsive to preoperative paclitaxel or cisplatin chemotherapy.

Abstract P1-14-02: A phase 2 study of low dose metronomic eribulin in metastatic breast cancer

Background: Eribulin mesylate is a non-taxane microtubule dynamics inhibitor approved by FDA in treatment of metastatic breast cancer (MBC) based on improvements in overall survival in the pivotal EMBRACE trial. Eribulin is approved at 1.4mg/m2 administered D1,8 of q21d cycle. However, this dose and schedule may have significant myelosuppression and peripheral neuropathy requiring dose reductions and treatment delays for some patients. We hypothesized that a low dose metronomic schedule will allow responding patients to remain on treatment, resulting in longer TTP (time to progression) and decreased incidence of toxicities and treatment-related discontinuations.

Methods: A multi-site prospective open-label phase II trial of metronomic dosing of eribulin in patients with MBC has completed accrual of 60 patients, outcomes will be updated at presentation. Patients whose disease had progressed following 1-6 prior regimens with prior exposure to a taxane, ECOG performance status of 0 – 2, measurable disease per RECIST 1.1, with normal marrow and organ function were eligible. Eribulin was administered at 0.9mg/m2 weekly for 3 out of 4 weeks. For patients with HER2 positive disease, concurrent trastuzumab administration was allowed. Concurrent denosumab or bisphosphonates were allowed for patients with bone disease.

Results: 60 patients were enrolled, average age 58 (range 34-83). Majority were postmenopausal Caucasian females, but the study included African American, Hispanic, native American, male patients. The majority of tumors were ER+, infiltrating ductal, but the study included 13 HER2+, and 12 TN tumors, with 5 ILC, and 5 mixed ILC/IDC. Nearly half of the enrolled patients had clinical benefit from the regimen, remaining on therapy for 6 months or longer, with stable disease or response; 50% had progression PD at 3 months 32% had stable disease and 18% had a partial or complete response (1, long term). Overall Survival, OS, for the entire group of heavily pre-treated patients was 1.2 years, with TN and HER2 positive patients faring better than ER+ in this small study. One HER2+ patient remains in long-term remission, off chemotherapy.

The regimen was extremely well tolerated. The majority of the patients experienced grade 0 or 1 toxicity for alopecia (48/60) and peripheral neuropathy (7 with grade 2 neuropathy, 5 pre-existing, 2 with grade 3 neuropathy). There were few dose reductions (n=15), thrombocytopenia (11 grade 1 only), or use of G-CSF (14).

Conclusions: Metronomic weekly low dose eribulin appears to be an active and tolerable regimen with less myelosuppression, alopecia and peripheral neuropathy than is seen with approved dose, allowing longer duration of use and disease control, with similar outcomes compared to the standard dose regimen. Outcomes will be updated at presentation.

Citation Format: Chalasani P, Liu AJ, Khanjian JA, Peha M, Buening BJ, Gadi VK, Specht JM, Salazar L, Linden HM. A phase 2 study of low dose metronomic eribulin in metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-14-02.

Abstract PD4-10: 18F-fluoroestradiol (FES) and 18F-fluorodeoxyglucose (FDG) PET imaging in staging extent of disease in metastatic lobular breast cancer

Background: The histology and pattern of spread in lobular breast cancer has presented challenges in estimating extent of disease and identifying treatment options. 18F-FES is an estrogen analogue PET imaging tracer which measures tumor ER expression at multiple tumor sites simultaneously and predicts response to endocrine therapy. We analyzed FES-PET and FDG-PET SUV uptake in patients with metastatic lobular and ductal carcinoma to identify sites of tumor and responsiveness to therapy.

Methods: We retrospectively reviewed FES and FDG SUV uptake between ER+ lobular (n = 36) and ductal (n= 173, including 6 men) metastatic breast cancer patients enrolled in various institutional studies. Up to 3 lesions in each patient were evaluated by FES SUVmax and/or FDG SUVmax for a total of 475 lesions in FES images and 462 lesions in FDG images. Classification into three categories (low FDG, high FDG/high FES, and high FDG/low FES) was generated using recursive portioning with 5-fold internal cross validation. Using a Pearson Chi-squared test, we compared degree of uptake in FES and FDG between lobular and ductal carcinomas. We used linear mixed effects model to assess association of FES SULmean3 (Lean body mass adjusted SUV) and FDG SULmean3 with histology. Overall survival (OS), from time of FES-PET scan to death, and progression free survival (PFS) was evaluated between classification groups in both histologies using Kaplan-Meier curves and Cox model.

Results: In patients with metastatic breast cancer, 72 patients had low FDG, 96 had high FES/high FDG, and 41 with high FES/low FDG. Lobular lesions tended to have a higher proportion of patients in the risk group with lower FDG (42% vs 33%) and a lower proportion in the risk group with high FDG/low FES (11% vs 21%) but the difference was not statistically significant (p = 0.32). Mean (range) FES SULmean3 and FDG SULmax3 respectively for ductal was 1.38 (0.10, 6.7) and 3.17 (0.88, 12.26) and for lobular was 1.42 (0.34, 3.43) and 3.13 (1.04, 13.87). There was no significant difference between in FES SULmean3 and FDG SULmax3 between histologies. Following FES-PET imaging, patients with lobular carcinomas and low FDG demonstrated a higher median survival time (7.7 years) compared to high FDG/low FES (4.3 years) and high FDG/high FES (2.6 years). Similarly, patients with ductal carcinomas and low FDG had an improved median survival time (5.6 years) compared to both high FDG/high FES (2.9 years) and high FDG/low FES (2.5 years). However, the interaction between histology and the FDG/FES classifications was not significant (p = 0.86). Across a variety of tumor sites, lobular histology can be detected by both FES and FDG with no difference between the imaging modalities.

Conclusions: In the metastatic setting, quantitative FES and FDG can be used to discriminate indolent and aggressive phenotypes in both lobular and ductal breast cancer. A greater proportion of lobular carcinoma lesions had higher FES/lower FDG and would be anticipated to be more sensitive to endocrine therapy. Further prospective trials are needed to confirm the utility of FES to stage extent of disease in metastatic breast cancer.

Citation Format: Manohar PM, Peterson LM, Wu V, Jenkins IC, Novakova-Jiresova A, Specht JM, Link JM, Krohn KA, Kinahan PE, Mankoff DA, Linden HM. 18F-fluoroestradiol (FES) and 18F-fluorodeoxyglucose (FDG) PET imaging in staging extent of disease in metastatic lobular breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-10.

Abstract PD3-14: Phase 1 study of the antibody-drug conjugate SGN-LIV1A in patients with heavily pretreated triple-negative metastatic breast cancer

Background

LIV-1, a transmembrane protein and downstream target of STAT3, is highly expressed in breast cancer cells. It is associated with lymph node involvement and metastatic progression. SGN-LIV1A is an anti-LIV-1 antibody conjugated via a protease-cleavable linker to monomethyl auristatin E (MMAE). Upon binding to cell-surface LIV-1, SGN-LIV1A is internalized and releases MMAE, which disrupts microtubulin and induces apoptosis.

Methods

This ongoing, phase 1 study evaluates safety, tolerability, pharmacokinetics, and antitumor activity of SGN-LIV1A (q3wks IV) in women with LIV-1-positive, unresectable, locally advanced or metastatic breast cancer (LA/MBC) (NCT01969643). Patients (pts) with measurable disease and ≥2 prior cytotoxic regimens for LA/MBC are eligible. Pts with ≥ Grade 2 neuropathy are excluded. Response is assessed per RECIST v1.1; pts with stable disease (SD) or better can continue treatment until disease progression or intolerable toxicity. At completion of dose escalation in hormone receptor-positive/HER2-negative (HR+/HER2–) and triple-negative (TN) pts, expansion cohorts were opened to further evaluate safety and antitumor activity of monotherapy in TN pts. Tumor biopsies are evaluated for LIV-1 expression.

Results

To date, 69 pts (18 HR+/HER2–, 51 TN) have received a median of 3 cycles (range, 1–12) of SGN-LIV1A at doses of 0.5–2.8 mg/kg. Median age was 56 yrs. Pts had a median of 3 prior cytotoxic regimens for LA/MBC; 58 had visceral disease and 37 had bone metastases. No dose-limiting toxicities (DLTs) occurred in 19 DLT-evaluable pts; maximum tolerated dose was not exceeded at 2.8 mg/kg. Expansion cohorts of TN pts were opened at 2.0 and 2.5 mg/kg. Treatment-emergent adverse events (AEs) reported in ≥25% of pts were fatigue (59%), nausea (51%), peripheral neuropathy (44%), alopecia (36%), decreased appetite (33%), constipation (30%), abdominal pain, diarrhea, and neutropenia (25% each). Most AEs were Grade 1/2; AEs ≥ Grade 3 included neutropenia (25%) and anemia (15%). Febrile neutropenia occurred in 2 pts whose total dose exceeded 200 mg per cycle, including 1 treatment-related death due to sepsis. No other treatment-related deaths occurred on-study. Seven pts discontinued treatment due to AEs. In dose escalation, activity was observed in 17 efficacy evaluable (EE) HR+/HER2- pts, with a disease control rate (DCR= CR+PR+SD) of 59% (10 SD), including 1 pt with SD ≥24 wks. Among the 44 EE TN pts (dose escalation plus expansion cohorts), the objective response rate (ORR) was 32% (14 PR) with a confirmed PR rate of 21%, DCR was 64% (14 PR, 14 SD), and clinical benefit rate (CBR=CR+PR+SD ≥24 wks) was 36% (16 pts). For TN pts, median PFS was 11.3 wks (95% CI: 6.1, 17.1); 10 pts remain on treatment.

Of 631 MBC tumor samples of all clinical subtypes evaluated for LIV-1, 91% were positive; 75% had moderate-to-high expression (H-score ≥100).

Conclusions

LIV-1 is expressed in almost all MBC tumors. SGN-LIV1A monotherapy was generally well tolerated and showed encouraging antitumor activity in heavily pretreated TN MBC, with a PR rate of 32%, confirmed PR rate of 21%, and CBR (≥24 wks) of 36%. Response duration data continue to evolve. Enrollment continues in the TN monotherapy expansion cohort.

Citation Format: Modi S, Pusztai L, Forero A, Mita M, Miller KD, Weise A, Krop I, Burris III H, Kalinsky K, Tsai M, Liu MC, Hurvitz SA, Wilks S, Ademuyiwa F, Diab S, Han HS, Kato G, Nanda R, O'Shaughnessy J, Kostic A, Li M, Specht J. Phase 1 study of the antibody-drug conjugate SGN-LIV1A in patients with heavily pretreated triple-negative 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 PD3-14.

Abstract P5-14-10: Weekly doxorubicin and daily oral cyclophosphamide followed by nab-paclitaxel for adjuvant therapy of high-risk localized breast cancer

BACKGROUND: The addition of taxanes to anthracycline-based adjuvant chemotherapy has improved disease free survival (DFS) in women with high-risk early-stage breast cancer. Many studies have sought to optimize the dose intensity and density of these agents to produce improvements in outcome and tolerability. The purpose of this study was to assess the use of metronomic doxorubicin plus daily oral cyclophosphamide (AC) for 12 weeks followed by nab-paclitaxel (nP) for 12 weeks in this population. Those patients with Her2 positive disease were also given adjuvant trastuzumab.

METHODS: A non-randomized phase II clinical trial was designed to (1) test the DFS at 2 years compared to historical controls, (2) assess dose intensity delivered, (3) assess use of nP in the adjuvant setting, and (4) evaluate toxicities associated with the regimen. Overall survival (OS) was a secondary outcome. The dosing of A was 24mg/m2 IV qweek and C was 60mg/m2 oral daily; nP, 100mg/m2 IV qweek.

RESULTS: Sixty patients were enrolled on the study with a median follow-up of 6 years and a median age of 50 (range 30-69). 58% of patients had node positive disease. Receptor categories included hormone receptor positive (ER positive or PR positive) and HER2 negative (n=24; 40%); ER negative, PR negative, and HER2 negative (triple negative; n=19; 32%); or HER2 positive (n=17; 28%). DFS at 2 years was 93% (1 death, 3 recurrence) and at 6 years was 82%, comparable to historical controls. OS at 2 years and 6 years was 98% and 88%, respectively. Mean dose intensity was greater than 90% for AC and 88% for nP. Treatment was well-tolerated with the most common grade ≥3 toxicity being neutropenia and a 2% incidence of febrile neutropenia.

Disease-free survival and overall survival at 2 and 6 years 2 year 6 year  DFS %OS %DFS %OS %All patients93988288ER+ or PR+, HER2-921007979Triple negative89957989HER2+10010088100

CONCLUSSIONS: Patients achieved similar DFS to that seen in historical controls with similar rates of adverse events. Since nP dosing was 100 mg/m2, even with 88% dose intensity, the delivered taxane dose is greater than standard weekly paclitaxel. Notably disease control was particularly impressive in the triple negative subtype, which has been shown to benefit from nP over standard paclitaxel in the neoadjuvant setting in the GeparSepto (GBG 69) trial. Metronomic AC followed by nP is a safe, effective option for delivery of adjuvant chemotherapy for high-risk patients.

Citation Format: Cho E, Wu Q, Rubinstein L, Linden H, Gralow J, Specht J, Gadi V, Ellis G. Weekly doxorubicin and daily oral cyclophosphamide followed by nab-paclitaxel for adjuvant therapy of high-risk localized breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-14-10.

Abstract P4-22-11: Combined targeted therapies for advanced triple negative breast cancer: A phase II trial of nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib

Background: Chemotherapy remains the mainstay of therapy for patients with metastatic triple negative breast cancer (TNBC). We hypothesized that the addition of biologic agents targeting key pathways (bevacizumab targeting angiogenesis and erlotinib directed against EGFR) may prolong progression free survival (PFS) and offer a novel treatment strategy free from chemotherapy for patients with metastatic TNBC.

Methods: Patients with TNBC receiving initial therapy for metastatic disease were eligible for this multicenter phase II trial (NCT00733408) conducted at an academic center and affiliated, community practice sites. Induction therapy included nab-paclitaxel 100 mg/m2 IV Qweek (wk) and Bevacizumab 10 mg/kg IV Q2wks x 24 weeks. Patients free of progression at 24 wks began maintenance therapy with bevacizumab 10 mg/kg IV Q2wks and erlotinib 150 mg po daily until progression with radiographic assessment every 8 wks. Primary objective was PFS with secondary objectives of response rate, overall survival (OS) and safety. All eligible patients were included in the analysis of PFS and OS. Response was evaluated among patients with measurable disease by RECIST 1.1 with central review. Patients with inadequate disease assessments were coded as non-responders. Kaplan-Meier method was used to estimate PFS and OS with patients censored at date of last tumor assessment (PFS) or date of last follow up (OS).

Results: From April 2009 – December 2015, 58 patients (median age 54, range 33-83) were enrolled; 56 (97%) had measurable disease, and all had metastatic TNBC by local assessment. 33 (57%) patients completed induction; 22 (38%) came off study during induction; 3 (5%) continue on maintenance therapy. 4 patients discontinued therapy prior to first assessment. As of June 8, 2016, 53 patients (91%) have progressed. Median follow up for surviving patients is 14.5 months (range 4.1-65.4). Median PFS is 7.7 months (95% CI 5.7, 9.5). Of 56 patients with measurable disease, 38 (66%) had partial response (PR); 10 (17%) with stable disease for clinical benefit rate (CBR) of 86%. Median OS is 18.2 months (95% CI 16.3, 24.5). Most common grade 3-4 toxicities during induction were neutropenia [17 (29%), 1 grade 4], fatigue [13 (22%), all grade 3], leukopenia [7 (12%), all grade 3], and neuropathy [7 (12%), all grade 3]. Rash was most common ≥ grade 3 toxicity during maintenance [4 (7%), grade 3]. One patient experienced clinical CHF during maintenance month 16 requiring bevacizumab discontinuation. Conclusions: Nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib was well tolerated. While the observed PFS did not meet pre-specified criteria of interest, the majority of patients experienced clinical benefit (86%) with 30 (57%) receiving maintenance targeted therapy. Correlative studies are ongoing. Supported by Genentech (OSI4266s), Celegene (AX-CL-BRST-PI-003828) and Janssen.

Citation Format: Specht JM, Gadi VK, Gralow JR, Korde LA, Linden HM, Salazar LG, Rodler ET, Cundy A, Buening BJ, Baker KK, Redman MW, Kurland BF, Garrison MA, Smith JC, vanHaelst C, Anderson JE. Combined targeted therapies for advanced triple negative breast cancer: A phase II trial of nab-paclitaxel and bevacizumab followed by maintenance targeted therapy with bevacizumab and erlotinib [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-11.

Abstract P4-02-05: Test-retest fidelity of FDG SUVmax in bone and non-boney metastatic breast cancer lesions in local area network PET/CT scanners

Background: Metabolic activity in lesions, measured by FDG-PET, is often used for assessing tumor aggressiveness and response to therapy. Patients may be scanned on different machines, so quantitative measurements should be reproducible. Reducing SUV variability in PET machines throughout a local network can aid in monitoring patient response to therapy and increase access to clinical trials.

Methods: Eighteen female patients with advanced or metastatic breast cancer underwent paired FDG PET/CT test-retest studies with 1-15 days between scans, and without interim change in treatment. Ten patients were studied in the same scanner and 8 patients were studied in 2 different scanners. Five different PET/CT scanners were used (2 GE DSTE, 2 Siemens (BioGraph 6 and mCT), 1 Philips Ingenuity TF). Each PET/CT scanner was calibrated using NIST-traceable reference sources to characterize and reduce variability. All of the images were interpreted by two separate reviewers. SUVmax values in lesions, corresponding normal tissue, and normal liver were collected. Linear mixed models with random intercept (patient effects) were fitted to compare differences in log(|SUVmax % difference|+.01) in multiple lesions per patient.

Results: SUVmax was assessed in a total of 130 lesions (75 bone). The median number of lesions per patient was 5 (range 1-17). Average SUVmax ranged from 1.0 to 18.2 (mean±SD = 6.0±3.2). The median SUVmax difference was 0.4 (8%) for 47 lesions imaged twice in the same scanner, and was 0.6 (13%) for 83 lesions imaged in two different scanners. In a multivariable linear mixed effects model, SUVmax for different scanners within the same institution did not differ more than for the same scanner (p=0.39), but repeat scans with different scanners and site personnel at had an average of 78% greater percentage difference in SUVmax than for the same scanner (p=0.009). In the same model, the average percent difference in SUVmax for bone lesions was estimated as 30% lower than for other sites (p=0.06, 95% confidence interval 0-50%). Examining normal liver uptake, the median SUVmean was 2.5 (range 1.9-3.1) with an median 6.5% difference between measurements (range 1.1%-23.7%) that did not appear to differ based on scanners used for repeat measurements (p=0.47).

Conclusions: The variability in quantitative FDG SUVmax between scans is modest, suggesting reliable reproducibility in appropriately calibrated settings. In our study, bone lesions had somewhat higher fidelity than other tumor sites. Additional studies will address variability in other cancer types. Careful calibration and monitoring of PET/CT scanners, and consistent imaging protocols are necessary in clinical trials that utilize quantitative PET/CT imaging in order to confidently interpret results.

Research Support: NIH grant U01-CA148131 and NCI-SAIC Contract 24XS036-004.

Citation Format: Linden HM, Peterson LM, Kurland B, Roberts T, Specht J, Shields AT, Novakova A, Christopfel R, Byrd D, Muzi M, Mankoff DA, Kinahan P. Test-retest fidelity of FDG SUVmax in bone and non-boney metastatic breast cancer lesions in local area network PET/CT scanners [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-02-05.

Abstract P6-12-04: Phase 1 study of the antibody-drug conjugate (ADC) SGN-LIV1A in patients with heavily pretreated metastatic breast cancer

Background

LIV-1, a transmembrane protein and downstream target of STAT3, is highly expressed in breast cancer cells. It is associated with lymph node involvement and metastatic progression. SGN-LIV1A is an anti-LIV-1 antibody conjugated via a protease-cleavable linker to monomethyl auristatin E (MMAE). Upon binding to cell-surface LIV-1, SGN-LIV1A is internalized and releases MMAE, which binds to tubulin and induces G2/M arrest and apoptosis.

Methods

This is an ongoing, phase 1 dose-escalation study evaluating safety, tolerability, pharmacokinetics, and antitumor activity of SGN-LIV1A (q3 wks IV) in women with LIV-1-positive, unresectable, locally advanced or metastatic breast cancer (LA/MBC) (NCT01969643). Patients (pts) with measurable disease and ≥2 prior cytotoxic regimens for LA/MBC were eligible. Pts with ≥Grade 2 neuropathy were excluded. Response was assessed per RECIST v1.1; pts with stable disease (SD) or better could continue treatment until disease progression or intolerable toxicity. At completion of dose escalation in hormone receptor-positive/HER2-negative (HR+/HER2–) and triple-negative (TN) pts, expansion cohorts were opened to further evaluate safety and antitumor activity of monotherapy in TN pts and combination therapy with trastuzumab (Tz) in HER2-positive (HER2+) pts. Pre- and post-treatment tumor biopsies were done to evaluate LIV-1 expression and other correlative endpoints.

Results

To date, 39 pts (18 HR+/HER2–, 21 TN) have received a median of 3 cycles (range, 1–10) of SGN-LIV1A monotherapy at doses of 0.5–2.8 mg/kg. Median age was 57 yrs (range, 33–79). At baseline, pts had a median of 4 prior cytotoxic regimens for LA/MBC (range, 2–8); 36 had visceral disease and 25 had bone involvement. No dose-limiting toxicities (DLT) occurred in 19 DLT-evaluable pts; maximum tolerated dose was not exceeded at 2.8 mg/kg. Treatment-emergent adverse events (AEs) reported in ≥30% of pts were: fatigue (64%), nausea (54%), alopecia (46%), decreased appetite (41%), constipation (39%), neutropenia (33%), and vomiting (31%). Peripheral neuropathy was reported in 9 pts (23%). Most AEs were Grade 1/2, except neutropenia (all ≥Grade 3). Four pts discontinued treatment due to AEs (acute respiratory distress syndrome, nausea, pneumonia, tachycardia). In dose escalation, modest activity was observed in 17 efficacy evaluable (EE) HR+/HER2- pts, with a disease control rate (DCR) of 59% (10 SD), including 1 pt with SD≥24 wks. Among the 17 EE TN pts (dose escalation plus cohort expansion), the overall response rate (ORR) was 41% (7 PR), DCR was 82% (7 PR, 7 SD) and clinical benefit rate (CBR=OR+SD≥24 wks) was 53% (9 pts). For TN pts, median PFS was 17.1 wks (95% CI: 6.0, 18.4); 6 pts remain on treatment.

Of 281 MBC tumor samples evaluated for LIV-1, 93% were positive; 81% had moderate-to-high expression (H-score ≥100).

Conclusions

LIV-1 is expressed in almost all MBC tumors. SGN-LIV1A monotherapy has been generally well tolerated and shown encouraging antitumor activity in heavily pretreated TN MBC, with a PR rate of 41% and a CBR at ≥24 wks of 53%. Response duration data continue to evolve. Enrollment continues in the TN monotherapy expansion cohort and the HER2+ combination cohort with Tz.

Citation Format: Forero-Torres A, Modi S, Specht J, Miller K, Weise A, Burris III H, Liu M, Krop I, Pusztai L, Kostic A, Li M, Mita M. Phase 1 study of the antibody-drug conjugate (ADC) SGN-LIV1A in patients with heavily pretreated metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-12-04.

Abstract P5-01-02: Multimodality molecular imaging with dynamic 18F-fluorodeoxyglucose positron emission tomography (FDG PET) and MRI to evaluate response and resistance to neoadjuvant chemotherapy (NAC)

Background: Using quantitative FDG PET to measure glucose metabolism and perfusion, and dynamic contrast-enhanced (DCE) MRI to measure perfusion, we previously identified a metabolic signature for breast cancer resistant to NAC. This imaging signature is (1) persistent or increased tumor perfusion despite treatment, (2) an altered pattern of glucose kinetics in response to therapy, and (3) pre-therapy mismatch between tumor metabolism (MRFDG) and glucose delivery (K1) (high ratio of MRFDG/K1). These patterns predict poor response, early relapse and death independent of established prognostic factors, including pathologic response. Identification of factors associated with resistance or response to therapy is the translational goal of "Quantitative Dynamic PET and MRI in Breast Cancer Therapy," part of the Seattle Breast SPORE (1P50CA138293).

Methods: Patients (Pts) undergoing NAC for histologically confirmed breast cancer (stage II-III) were approached for this trial (CCIRB# 7587). FDG PET and DCE-MRI were obtained pre-therapy, 2-12 weeks after start of NAC (mid-therapy) and after completion of NAC. Breast biopsies were obtained pre-therapy and post-NAC. FDG PET included a dynamic scan with kinetic analysis. PET measures included SUVmax, MRFDG, K1, Ki, and Patlak. 3T DCE-MRI measurements included semi-quantitative vascular parameters of peak enhancement (PE), signal enhancement ratio (SER), washout fraction, functional tumor volume, and apparent diffusion coefficient (ADC) from diffusion-weighted MRI (DWI). Breast biopsies were assayed by immunohistochemistry and gene expression profiling. NAC was per physician's choice with most pts receiving weekly paclitaxel (with trastuzumab if HER2+) followed by doxorubicin/cyclophosphamide.

Results: 32 pts have completed the study. Pathologic complete response (pCR), defined as absence of invasive cancer in the breast, was observed in 9 (28%); near pCR defined as only microscopic residual invasive cancer in 3 (9%) more pts. Mid-therapy decline in SUVmax and K1 was associated with near pCR; (p-value 0.06, 0.04, respectively). Pre-therapy PET measures of MRFDG and K1 were not predictive of pCR. On MRI, pre-therapy PE (p=0.009), SER (p=0.01), washout fraction (p=0.02), ADC (p=0.08, trend) and mid-therapy change in volume (p=0.05) were each predictive of pCR. Gene profiling of pre-therapy biopsies showed correlation between high MRFDG/K1 ratio in basal and luminal B tumors.

Conclusions: Assessment of serial changes in tumor metabolism and perfusion by FDG PET and DCE-MRI is feasible in the clinic. Mid-therapy decline in metabolism and glucose delivery was predictive of pCR; consistent with prior retrospective series. Baseline DCE-MRI and DWI measures show promise to predict response, and associations of mid-therapy change in MR functional tumor volume with pCR agree with findings of another multisite clinical trial (ISPY). These imaging parameters may serve as useful biomarkers to inform future neoadjuvant trials. Integration of imaging data with gene expression profiling revealed that the pattern of metabolism in luminal B tumors was closer to that of the basal subtype compared to other ER-positive tumors.

Citation Format: Specht JM, Partridge S, Chai X, Novakova A, Peterson L, Shields A, Guenthoer J, Linden HM, Gralow JR, Gadi V, Korde L, Hills D, Hsu L, Hockenbery DM, Kinahan P, Mankoff DA, Porter PL. Multimodality molecular imaging with dynamic 18F-fluorodeoxyglucose positron emission tomography (FDG PET) and MRI to evaluate response and resistance to neoadjuvant chemotherapy (NAC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-01-02.

Abstract P1-03-01: Circulating CAIX as a biomarker in breast cancer

Introduction: Carbonic anhydrase-IX (CAIX) facilitates the reversible hydration of carbon dioxide to bicarbonate and protons, a process integral to maintaining pH differences across the cancer cell plasma membrane. CAIX is regulated by hypoxia inducible factor-1 alpha (HIF-1 alpha) and is essential for the elimination of acid loads generated by glycolysis. High CAIX expression is associated with poor prognosis and chemoresistance in breast cancer patients (pts) (1-3). To explore the role of CAIX as a possible biomarker for predicting breast cancer therapies, we measured plasma CAIX levels in response to various chemotherapy regimens, including anti-angiogenics, in several breast cancer clinical trials.

Methods: Circulating plasma CAIX was quantified using a commercially available enzyme-linked immunosorbent assay (ELISA) kit (R & D Systems). We evaluated the plasma stability of CAIX by quantifying levels within 1 hour as well as at 24 and 48 hours post phlebotomy in healthy controls (n = 10). We also evaluated the ideal anticoagulant for sample collection and stability of CAIX levels over time in healthy controls. For our analysis in breast cancer pts, we quantified plasma CAIX levels in two populations treated on chemotherapeutic clinical trials: 1) locally advanced breast cancer (LABC) pts treated in the neoadjuvant setting with paclitaxel in combination with sunitinib followed by anthracycline (AC) based chemotherapy (n = 63); 2) metastatic breast cancer (MBC) pts treated with systemic chemotherapy with either irinotecan + etoposide; or paclitaxel + a novel immunomodulatory agent (n = 22).

Results: In healthy control subjects, plasma levels of CAIX were stable at all time points tested (within1 hour, 24 hrs, 48 hours post phlebotomy) with no significant change on repeat testing at 6 months. Average baseline plasma CAIX levels were lowest in normal controls (20.5 pg/ml) compared to pts with LABC (34.1 pg/ml) or MBC (90.7 pg/ml) (p = <0.001). In pts with LABC, CAIX rose significantly in response to paclitaxel/sunitinib (TS) therapy (p = 0.01) but not further with anthracycline based therapy (p = 0.37). The rise in response to TS was primarily in pts with baseline levels below the median. In pts with MBC treated with cytotoxic chemotherapies (without an anti-angiogenic) CAIX levels did not change in response to therapy.

Discussion: Plasma CAIX is a robust biomarker that is stable at room temperature in plasma for at least 48hrs and over time in healthy controls. Plasma CAIX levels are elevated in pts with MBC when compared to those with LABC or normal controls. CAIX levels rise in response to anti-angiogenic therapy but not in response to cytotoxic chemotherapy. Our results suggest CAIX may be a robust and easily measured pharmacodynamic biomarker of anti-angiogenic induced hypoxia and HIF-1 alpha upregulation.

1. Potter CP and Harris AL. Br J Cancer. 89:2-7, 2003.

2. Betof AS, Rabbani ZN, Hardee ME, et al. BJ Cancer. 106:916-922, 2012.

3. Generali D, Fox Berruti A, et al. Endocrine-Related Cancer. 13:921-30, 2006.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-03-01.

Abstract P4-01-03: HDACi (vorinostat) in metastatic breast cancer to restore sensitivity to ER-directed (AI) therapy: A phase II clinical trial with FES imaging correlates

Background: Histone deacetylase inhibitors (HDACi) have shown pre-clinical promise in estrogen receptor(ER)-modulation and restoring sensitivity to endocrine manipulation, suggesting potential clinical benefit (Sabnis 2011) (Huang 2000) in ER+ breast cancer. Vorinostat is an FDA-approved HDACi for CTCL, and could have a beneficial role in restoring ER-signaling in endocrine-resistant tumors (Munster 2011) (Yardley 2011). [F-18]fluoroestradiol (FES) PET imaging may be used to monitor regional tumor ER expression in patients with breast cancer (Linden 2011).

Methods: Patients with metastatic breast cancer with prior clinical benefit from endocrine manipulation who progressed on an AI therapy are eligible for this ongoing trial. In part A, patients were given vorinostat for 2 weeks, then resumed AI for 6 W. In part B (reflecting results of prior HDACi trials) patients are given vorinostat 400mg po daily 5/7 days 3/4 weeks while AI is given continuously. Paired FES and FDG PET are performed at baseline, week 2 and 8; clinical/radiologic assessment of disease is also performed at week 8. Patients with clinical benefit (response or stable disease) may continue on treatment until progressive disease or study withdrawal. Lesion-level analysis of the association between baseline FES uptake (logged) and FES/FDG ratio used generalized estimating equations (GEE) with small-sample adjustments to standard errors.

Results: 12/ 20 planned patients have accrued, and the treatment is well tolerated. Enrolled women were postmenopausal, the majority with primary infiltrating ductal tumors, bone/soft tissue dominant with longstanding metastatic disease, exposed to multiple endocrine and chemotherapy regimens. Five patients have had clinical benefit (2/4 on part B with greater HDACi exposure). One patient withdrew from the study due to toxicity. FES and FDG uptake was analyzed in 42 lesions in 11 patients. Average FES uptake was 2.0 (SULmean) for patients with clinical benefit, and 1.2 in patients with progressive disease by 8 weeks (p = 0.09). FES/FDG ratio at baseline was also associated with response (p = 0.04).

Conclusions: HDACi therapy is promising in relapsed ER+ breast cancer. Imaging of metabolic pathways in parallel with clinical trials may accelerate understanding of the underlying tumor biology and refine treatment selection.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-03.

Abstract P4-01-02: The role of FLT PET early assessment of response to endocrine therapy for early stage breast cancer

Background: In estrogen receptor positive (ER+) tumors, a low proliferative index (Ki-67) two weeks into endocrine therapy predicts response. FLT PET non-invasively measures tumor proliferation in vivo. The pre-operative window is an opportunity to assess impact of systemic therapies. We tested associations between FLT PET qualitative and quantitative measures and Ki-67 following two weeks of aromatase inhibitor (AI) therapy.

Methods: Women with clinical stage I-II ER+ HER2– breast cancer underwent “run-in” of AI monotherapy prior to definitive surgery. Premenopausal women were given GNRH agonist treatment 2 W prior to AI therapy. FLT PET was performed before AI therapy, and 1-7 days before surgery. Ki-67 was measured in baseline core biopsy and surgical specimens.

Results: Fourteen patients (8 postmenopausal, 6 premenopausal) have been enrolled. All have undergone baseline FLT PET imaging; 11 have completed imaging and surgery, including one premenopausal patient with no residual invasive carcinoma following 26 days of AI therapy. The majority harbored ductal carcinomas (n = 9, 5 with lobular histology) with the majority histologic grade ≥ 2 (n = 11). The median number of days exposed to AI was 19 (range, 9-42). Baseline SUVmax ranged from 1.2 to 3.9 (median 2.2), and post run-in SUV (6-64 days later) ranged from 1.2 to 2.8 (median 1.8). Baseline Ki-67 ranged from 6-26.2, median 11.6; surgical Ki-67 post AI therapy ranged from 0- 20.3 median 3.7, with seven below 5%. SUV and flux declined in most patients, as did Ki-67.

Quantitative FLT flux correlated with tumor response assessed by proliferative index (Ki-67) before the “run-in” period, with a stronger correlation at surgery, Pearson correlation coefficients = 0.41 and 0.82, respectively. FLT SUV and qualitative changes were not strongly associated with Ki-67.

Conclusions: Both pre and postmenopausal women with early stage breast cancer showed imaging and tissue response to endocrine therapy. Quantitative, but not qualitative FLT is a promising tool to assess tumor proliferation and response to therapy. Accrual is ongoing and updated results will be reported.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-01-02.

Abstract P6-04-03: Changes in breast tumor metabolism and estradiol binding as measured by FES PET in patients treated with the histone deacetylace inhibitor vorinostat and aromatase inhibitor therapy

Background: Some estrogen receptor-positive (ER+) metastatic breast cancers are bone and soft tissue dominant, indolent, and controlled by endocrine therapy. However, these tumors eventually become refractory to endocrine therapy and need a mechanism to reset the “estrogen-dependence” to allow continued benefit upon progression. Histone deacetylase inhibitors (HDACi) act as modulators of gene expression that are promising therapeutic agents for this group of tumors (Huang 2000, Sabnis 2011). Preclinical and clinical data demonstrate in ER-poor tumors and cell lines ER up-regulation and consequently enhanced lethality to endocrine agents. The optimal dose and schedule are not known, but two promising phase II studies show benefit in a continuous schedule (Yardley 2011, Munster 2011). FES PET is a promising imaging agent used as a biomarker to determine which patients will benefit from endocrine therapy, and to monitor estradiol binding during therapy (Mortimer 2001, Linden 2011).

Methods: Patients with ER+ HER2− metastatic breast cancer with prior aromatase inhibitor (AI) exposure and clinical benefit of endocrine therapy were eligible for a phase II study of HDACi therapy to restore sensitivity to AI therapy. Following baseline FDG PET, FES PET and standard imaging (CT, MRI, ultrasound and/or bone scan as indicated by tumor location), patients received 2 weeks of vorinostat therapy (400 mg po daily). FES PET was performed at 2 weeks while on HDACi therapy. Patients then received 6 weeks of AI monotherapy. FDG PET, FES PET and response assessment were performed at 8 weeks. Patients with clinical benefit (stable disease or response) continued on the regimen, 2 weeks of vorinostat followed by 6 weeks of AI.

Results: To date, 8 patients have been enrolled of whom 6 have completed the first 8 weeks of treatment and all correlative imaging studies. FES biomarker imaging results are mixed, with some patients showing an increase in tumor estradiol concentrating ability by FES PET on HDACi therapy, and decline in metabolic activity by FDG. Two patients continue on treatment with clinical benefit. Results will be updated as accrual continues.

Conclusions: Changes in estradiol binding are measured by serial FES PET in patients on HDACi therapy support preclinical concept of HDACi modulation of ER expression in metastatic breast cancer. Molecular imaging is a promising tool to monitor Estradiol binding pharmacodynamics, and Vorinostat HDACi therapy is a promising novel approach to allow patients to avoid toxicities of traditional chemotherapy once their tumor has progressed on endocrine therapy.

Funding: P01, MKA, Merck

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-04-03.

P1-17-04: Phase I Study of PARP Inhibitor ABT-888 (Veliparib) in Combination with Cisplatin and Vinorelbine for Patients with Advanced Triple Negative Breast Cancer and/or BRCA-Mutation Associated Breast Cancer

Background: Inhibitors of poly(ADP-ribose) polymerase (PARP) have shown preclinical and clinical activity in targeting tumors with pre-existing DNA repair defects, in particular BRCA1 and BRCA2 deficient tumors. Cisplatin (CP) has demonstrated synergy with ABT-888 (veliparib) in breast cancer xenograft models and has anti-tumor activity in triple negative (TN) and BRCA-1 deficient breast cancer. Vinorelbine (V) combined with CP has shown safety and efficacy in patients with pretreated metastatic breast cancer.

Methods: We are conducting a phase I study to determine the maximum tolerated dose (MTD), pharmacokinetic (PK) and pharmacodynamic profiles (PD), and preliminary anti-tumor activity of veliparib in combination with CP and V in patients (pts) with metastatic breast cancer who are either TN or who have BRCA1 or BRCA2 mutation associated breast cancer. Cohorts receive escalating doses of ABT-888 orally BID days 1–14, CP 75 mg/m2 intravenously (IV) day 1 and V 25 mg/m2 IV days 1,8 every 21 days, in a 3+3 design.

Results: As of 6/14/11, 18 eligible female pts have been enrolled. The median age at registration was 50 years (range 34–78 years). Sixteen pts received at least one prior metastatic regimen (range 0–8). Three pts had previously treated brain metastases. BRCA mutation status was as follows: BRCA1+ (3 pts); BRCA2+ (2 pts); confirmed mutation negative (8 pts); unknown (5 pts). Four pts received the 20 mg BID veliparib dose (one patient in the cohort died of progressive disease early in cycle 1 and was replaced), 3 received 30 mg BID, 6 received 40 mg BID, and 5 have been enrolled at dose level 4 (60 mg BID). Dose limiting toxicities occurred in one patient at the 40 mg BID dose (grade 4 thrombocytopenia), and one patient at the 60 mg BID dose (grade 3 neutropenic fever). Adverse events are typical for a platinum-based chemotherapy regimen and include nausea, fatigue, thrombocytopenia, and neutropenia. MTD has not been reached. Of 11 pts evaluable for radiographic response to date, 6 (55%) had a PR (3 of whom have a BRCA mutation) and 5 (45%) had stable disease. Correlative studies will use immunohistochemistry and gene expression array to evaluate the profile of TN breast cancer and predictors of response to treatment.

Conclusion: Veliparib in combination with CP and V has been generally well tolerated to date. Objective anti-tumor activity was seen in BRCA mutation carriers and in pts with sporadic TN breast cancer. PK, PD, and biomarker analysis is underway. Enrollment continues in the dose escalation cohorts.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-17-04.

P2-08-03: Quantitative MRI for Noninvasive Prediction of Prognostic Markers in Breast Cancer

Background: Magnetic resonance imaging (MRI) is a valuable tool for assessing extent of breast cancer and monitoring treatment response. Quantitative measures by diffusion-weighted MRI (DWI) and dynamic contrast-enhanced (DCE) MRI reflect tumor cellularity and vascularity. Tumor grade and some histopathological markers, such as ER, PR, HER-2, Ki67 and P53, are prognostic factors that can also be associated with tumor cellularity and vascularity. DWI and DCE measures may therefore provide a noninvasive means for predicting disease prognosis and stratifying patients to appropriate therapies. The purpose of this study was to investigate the correlation between quantitative MRI features and prognostic pathological factors in patients with invasive breast cancer.

Methods: This IRB-approved retrospective study included patients with biopsy-proven invasive cancer who underwent 1.5T breast MRI (including DCE and DWI) from October 2005 to May 2006 prior to treatment. Pathology data was obtained from pre-treatment biopsy and intrinsic subtype classification was approximated by standard immunohistochemistry characteristics. After excluding cases with missing MRI or pathology data, the final study cohort included 41 invasive cancers (36 ductal and 5 lobular carcinomas) in 36 patients. MRI measures included lesion DCE kinetic features: peak initial enhancement (PE), percent rapid enhancement (RE), and percent washout (WO), and DWI normalized apparent diffusion coefficient values (nADC). Associations between imaging features and pathology markers, cancer grades and intrinsic subtypes were evaluated by Mann-Whitney U test and multivariate logistic regression.

Results: Results of univariate comparisons are summarized in Table 1. One or more DCE-MRI kinetic parameters were significantly predictive (p<0.05) of each of the histopathological markers with the exception of ER, which was marginally associated with WO (p=0.05). Each of the DCE kinetics parameters significantly discriminated grade III tumors from grades I and II and luminal A from luminal B and basal-like intrinsic subtypes. In multivariate regression, both PE and WO were significant independent predictors of tumor grade (p=0.0094, p=0.0005, respectively). WO and nADC were significant independent predictors of PR status (p=0.0054, p=0.0027), while PE was the only significant independent predictor of both Ki67 (p=0.014) and intrinsic subtype (p=0.015).

Conclusion: This preliminary study suggests that quantitative MRI measures are associated with prognostic tumor markers and may provide valuable noninvasive characterization of tumor biology. Larger prospective studies are needed to validate our findings.

P1-06-25: Changes in FDG PET SUV Correlates with Ki-67 Following 2 Weeks of Aromatase Inhibitor Therapy in ER+ Early Stage Breast Cancer, a Pilot Imaging Study

Background: In estrogen receptor positive (ER+) tumors, a low proliferative index (Ki-67) two weeks into endocrine therapy predicts response. FDG PET non-invasively measures tumor sites in vivo. The pre-operative window is an opportunity to assess impact of systemic therapies. We tested associations between FDG PET standardized uptake value (SUV) and Ki-67 after two weeks of aromatase inhibitor (AI) therapy in newly diagnosed, postmenopausal women.

Methods: Postmenopausal patients with clinical stage I-II ER+ HER2− primary tumors underwent a 9–35 day “run-in” of AI monotherapy prior to definitive surgery. FDG PET was performed before AI therapy, and 1–5 days before surgery. Ki-67 was measured in baseline core biopsy and surgical specimens.

Results: To date, 18 patients (median age 59) have been enrolled of whom 14 patients have undergone serial FDG PET imaging with 12 completed assessment of Ki-67 in surgical samples including one who had no residual invasive carcinoma. The majority harbored ductal carcinomas (n=16) with 10/18 having histologic grade ≥ 2. The median number of days exposed to AI was 18 (range, 9–35). Baseline SUV ranged from 1.8 to 10.9 (median 2.5), and post run-in SUV (7-34 days later) ranged from 1.0 to 10.7 (median 2.5). A median 14% decrease in SUV was observed between paired FDG PET studies (range, 44% decline to 13% increase). Five of 12 patients’ index lesion FDG SUV declined by 20% or more; all also had Ki-67 ≤5% at surgery. An additional 5 patients with Ki-67 ≤5% at surgery had percentage change in FDG PET SUV of 0% to 17% decline. Results will be updated as accrual is ongoing.

Conclusions: Substantial changes in FDG PET SUV in the breast tumor were appreciated early in AI therapy. SUV declined or was stable in all but one patient of 14, and all patients with ≥ 20% decrease in SUV had a low (≤5%) Ki-67 at surgery. Serial PET is a promising measure of early response to therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-25.

P2-09-09: Dynamic FDG PET and DCE-MRI To Assess Tumor Metabolism and Blood Flow in Response to Neoadjuvant Sunitinib and Paclitaxel Followed by AC + G-CSF in Patients with Locally-Advanced (LABC) and/or Inflammatory Breast Cancer (IBC)

Background

Kinetic analysis of FDG PET and DCE-MRI can identify patterns of breast tumor metabolism and perfusion that predict pathologic response, relapse, and survival in patients (pts) receiving neoadjuvant chemotherapy (NC). We are enrolling pts with LABC or IBC on a phase II trial of neoadjuvant sunitinib and metronomic chemotherapy. The addition of sunitinib, a tyrosine kinase inhibitor of VEGFR1-3, PDGFR, c-KIT, to NC is hypothesized to increase rate of pathologic complete response (pCR). Assessment of FDG PET measures of glucose metabolism (Ki), glucose delivery (K1) which approximates blood flow, and MRI measures of blood flow and vascularity (peak enhancement (PE), signal enhancement ratio (SER), and volume) during NC offers the opportunity to evaluate the in vivo pharmacodynamics of sunitinib.

Methods: Pts with HER2−negative LABC or IBC participated in a companion imaging trial with [18F]-FDG PET and DCE-MRI before NC (T0), after a 1 wk run-in of sunitinib 25 mg po daily (T1), after 12 wks of paclitaxel 80 mg/m2 IV Qwk and sunitinib 25 mg po daily (T2), and prior to breast surgery (T3) after 15 wks of doxorubicin 24 mg/m2 IV Qwk, cyclophosphamide 60 mg/m2 po daily with G-CSF 5 mcg/kg SC days 2–6 each wk. FDG metabolic rate (Ki), glucose delivery (K1), and MR indices (PE, SER, volume) were assessed. Imaging parameters were compared for groups defined by NC pathologic complete response (pCR) vs. non-pCR using a two-sample t-test.

Results: The imaging trial included 14 pts. Median age was 50 years (43-79). All had HER2−negative LABC (n=13, 93%) or IBC (n=1, 7%). Most tumors were ductal (n=12, 86%) and high grade (n=9, 64%). Seven (50%) tumors were ER negative. pCR was observed in 4/14 (29%) pts in this cohort. Changes in Ki, K1, and MRI volume were observed between baseline (T0) and the sunitinib run-in (T1). For example, 8/14 (57%) had a decrease in K1 of >20%, and 3 (21%) had an increase of ≥20%. These 1 week changes did not predict subsequent response to NC. However, declines in Ki and K1 between baseline (T0) and following sunitinib and paclitaxel (T2) did predict pCR. The average change in glucose metabolism (Ki) was a 95% decline with pCR and a 68% decline otherwise (p= 0.007). The average T0-T2 K1 change was 83% decline for pts with pCR and 47% decline otherwise (p= 0.029). In contrast to our previous studies in LABC pts treated with NC where decline in K1 was predictive of response, decline in Ki appears to be the more robust predictor of response in this cohort. Of 11 pts with PET scans at T2 and T3, 5 showed marked increase (>20%) in Ki and 6 showed marked increase in K1 after withdrawal of sunitinib.

Conclusion: Changes in breast tumor glucose metabolism (Ki), glucose delivery (K1), and blood flow (MR PE, SER, volume) can be detected after 1 wk of sunitinib, but are not predictive of response to NC. In the setting of anti-vascular therapy, measures of tumor glucose metabolism (Ki) are predictive and perhaps, more predictive of outcome than measures of glucose delivery (K1) which may be altered by sunitinib.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-09.

Dasatinib Plus Capecitabine for Advanced Breast Cancer: Safety and Efficacy Data from Phase 1 Study CA180-004

Background: SRC is a potential therapeutic target in breast cancer and has a central role in hormone therapy resistance and in osteoclast activity. Dasatinib is a potent SRC inhibitor that inhibits breast cancer cell proliferation and migration in vitro, including synergy with 5FU in some cell lines, and inhibits osteoclast activity in clinical trials. CA180-004 is a phase 1 study designed to identify dose-limiting toxicities (DLT) and recommended phase 2 doses of dasatinib plus capecitabine in women with advanced breast cancer (ABC). Safety and efficacy data are now reported with additional follow-up.Methods: Cohorts of pts with ABC were treated at four dose levels (DL) with capecitabine (mg/m2 twice daily [BID] on D1-14 of 21-day cycles) and dasatinib (mg daily): DL1: capecitabine 825 + dasatinib 50 BID; DL2: capecitabine 825 + dasatinib 70 BID; DL3: capecitabine 1000 + dasatinib 70 BID; DL3a: capecitabine 1000 + dasatinib 100 once daily (QD). All pts had performance status 0-1, prior taxane and/or anthracycline and ≤2 prior chemotherapy-containing regimens for advanced disease. Disease assessments were performed every 6 weeks. DL3a was expanded for further safety and efficacy estimate using best objective response and progression-free survival (PFS) rates.Results: To date, 47 pts with ABC have been treated, 31 in escalation phase plus 16 in expansion (5 too early). Median age was 52 years (range 35-77). Tumor subtypes: 14% were Her2-amplified, 57% ER+ or PR+, 29% triple-negative. Safety was previously reported (ASCO 2009) for escalation phase; no MTD was defined based on DLTs. Of 20 evaluable pts in DL3a, 2 DLTs have been observed: 1 pneumonia, pain and pleural effusion plus 1 diarrhea, neutropenia, vomiting, mucositis and anemia. The most common drug-related adverse events (AEs, any grade) were headache, fatigue/asthenia, nausea/vomiting, diarrhea, hand-foot syndrome (HFS) and pleural effusion. The most common grade 3/4 AEs were fatigue/asthenia, HFS, vomiting and diarrhea. To date, 19 have remained on treatment ≥4 months, including 3 for >1 year. Median duration of treatment (n=42) was 13 weeks; 23 pts have discontinued for progression and 7 for toxicity. Of 38 pts with on-study assessment, 6 had confirmed partial response (treatment durations 17+, 23, 25, 36+, 71, 73 wks), 6 had unconfirmed partial or clinical response (5, 11, 13, 18, 23+, 24 wks), and 9 had prolonged stable disease (16+, 17, 23+, 24+, 25+, 29, 39+, 48+, 63+ wks). Updated efficacy data, including PFS by hormone receptor status, will be presented.Conclusions: Dasatinib and capecitabine combination treatment was well tolerated and encouraging efficacy was observed. Further assessment of this combination is warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3092.

Dasatinib plus capecitabine (Cap) for progressive advanced breast cancer (ABC): Phase I study CA180004

1012

Background: SRC family kinases (SFK) mediate numerous signal-transduction pathways relevant to breast cancer as well as osteoclast function. Dasatinib, a potent oral inhibitor of SFK and other kinases has preclinical activity in breast models and in vitro synergy with Cap in some breast cancer cell lines (KPL-4 and HCC-70). A phase I trial of dasatinib plus Cap was conducted to define dose-limiting toxicities (DLT), maximum tolerated (MTD), and recommended phase II (RP2D) doses. Methods: Sequential cohorts of pts with ABC were treated with Cap twice daily (BID) on days 1–14 and dasatinib daily in 21-day cycles using dose levels (DL) for Cap (mg/m2) and dasatinib (mg): DL1: Cap 825 + dasatinib 50 BID; DL2: Cap 825 + dasatinib 70 BID; DL3: Cap 1000 + dasatinib 70 BID; DL3a: Cap 1000 + dasatinib 100 once daily (QD). All pts had ECOG performance status 0–1, had prior anthracycline and/or taxane, and received ≤2 regimens in advanced setting. MTD was based on DLT in first cycle and RP2D also based on tolerability of additional cycles. Results: 31 pts with ABC, median age 53 years (range 36–78) were treated. Number of pts treated/evaluable for DLT/reported DLT (event) were DL1: 7/6/1 (headache, grade 3); DL2: 9/7/0; DL3: 6/6/1 (diarrhea, grade 3), and DL3a: 9/9/1 (pneumonia, grade 3). Most frequent AEs related to either drug and occurring at any time on study (n pts) were nausea (12), vomiting (7), diarrhea (6), abdominal pain (2), fatigue (8), headache (7), musculoskeletal pain (1), and pleural effusion (4); hand-foot syndrome (5) was as expected for Cap alone. 11 patients experienced a Grade 3–4 non-hematologic AE at some point during the study. Laboratory abnormalities were uncommon. To date, 20 pts have continued treatment for ≥6 weeks and 9 pts for ≥12 weeks. Number of pts who (at any time) reduced dasatinib/reduced Cap/discontinued for toxicity were DL1: 2/2/1; DL2 2/2/3; DL3: 2/1/2; DL3a: 0/1/1. Updated safety and efficacy data will be presented. Conclusions: Dasatinib + Cap was tolerated without unexpected combined-treatment toxicity; few pts required dose reduction in later cycles. The recommended phase II dose, Cap 1000 plus dasatinib 100 QD, is well tolerated and will be studied for efficacy in an expanded patient cohort.

[Table: see text]

A single U/C nucleotide substitution changing alanine to valine in the beet necrotic yellow vein virus P25 protein promotes increased virus accumulation in roots of mechanically inoculated, partially resistant sugar beet seedlings

Beet necrotic yellow vein virus (BNYVV) A type isolates E12 and S8, originating from areas where resistance-breaking had or had not been observed, respectively, served as starting material for studying the influence of sequence variations in BNYVV RNA 3 on virus accumulation in partially resistant sugar beet varieties. Sub-isolates containing only RNAs 1 and 2 were obtained by serial local lesion passages; biologically active cDNA clones were prepared for RNAs 3 which differed in their coding sequences for P25 aa 67, 68 and 129. Sugar beet seedlings were mechanically inoculated with RNA 1+2/RNA 3 pseudorecombinants. The origin of RNAs 1+2 had little influence on virus accumulation in rootlets. E12 RNA 3 coding for V(67)C(68)Y(129) P25, however, enabled a much higher virus accumulation than S8 RNA 3 coding for A(67)H(68)H(129) P25. Mutants revealed that this was due only to the V(67) 'GUU' codon as opposed to the A(67) 'GCU' codon.

DCE-MRI and dynamic FDG PET to monitor breast cancer response to neoadjuvant sunitinib in patients with locally-advanced breast cancer

Abstract #6006

Background: We are enrolling patients with locally-advanced (LABC) or inflammatory breast cancer on a phase II trial of neoadjuvant sunitinib and metronomic chemotherapy. The addition of sunitinib is hypothesized to increase rate of pathologic complete response (pCR) via its effect on tumor vasculature. Measurement of FDG PET and MRI parameters of metabolism and blood flow (BF) after a one week run-in of sunitinib alone provides an opportunity to evaluate in vivo pharmacodynamics of sunitinib which may be predictive of response and provide insight into mechanism of sunitinib activity. Materials and Methods: Patients with HER2 negative LABC participated in an imaging trial with pre-therapy [18F]-FDG PET and DCE-MRI (T0) followed by a one-week run-in of sunitinib 37.5 mg orally daily with a second PET and MRI on day 7 (T1). FDG metabolic rate (MRFDG), transport (FDG K1) and MR indices of tumor perfusion (peak enhancement (PE), signal enhancement ratio (SER), and washout volume(WV)) were assessed. Results: Metabolism and perfusion parameters are available for the first 3 patients treated on this trial. All patients presented with grade 3, HER2 negative LABC. DCI-MRI (left) and PET images (right) pre-therapy (T0, top) and after one week sunitinib (T1, bottom) are illustrated in Figure 1. DCE-MRI studies show gray-scale images with color-coded regional perfusion (SER) superimposed; red indicates high levels of perfusion and blue lower levels. Three different responses were observed and expressed as percent change T0 to T1: patient 1 had no significant change in metabolism (MRFDG) or perfusion (K1,SER, PE); patient 2 showed a decline in perfusion with decreases in K1 (-55%), SER (-19%), PE (-10%), and WV (-56%), but minimal change in MRFDG (+ 5.9%); while patient 3 had marked declines in perfusion K1 (-41%), SER (-25%), WV (-78%) and MRFDG (-59%). Discussion: These early data demonstrate the ability to measure changes in tumor metabolism and blood flow by PET and MRI and illustrate heterogeneity in tumor response to sunitinib. As patients complete neoadjuvant chemotherapy (NC), metabolism and perfusion parameters from mid-therapy (T2) and end-therapy (T3) imaging will be evaluated in the context of pCR versus other with the goal of exploiting functional imaging parameters to predict response to NC and elucidate mechanism of response to sunitinib and metronomic chemotherapy. Supported by grant from NCCN, SI11.
 


Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6006.

Metabolism-perfusion mismatch as assessed by PET varies with breast cancer phenotype and predicts response to neoadjuvant chemotherapy

Abstract #6005

Background: Kinetic analysis of FDG and water PET can identify patterns of breast cancer metabolism and perfusion in patients receiving neoadjuvant chemotherapy (NC). Previously, we found that high pre-therapy glucose tumor metabolism relative to perfusion was associated with poor tumor pathologic response, early relapse, and death in patients with locally advanced breast cancer (LABC) treated with NC. This analysis examines tumor metabolism and perfusion as a function of tumor phenotype. Material and Methods: Tumor phenotype, defined by immunohistochemistry (IHC), was determined in 51 patients undergoing NC between 1995 and 2005. Luminal tumors were defined as those expressing either estrogen receptor (ER) or progesterone receptor (PR). The triple-negative (TN) phenotype was defined as ER and PR negative without HER2 overexpression by IHC or amplification by FISH. HER2 phenotype showed HER2 overexpression or amplification but were ER/PR negative. Women with LABC underwent dynamic [18F]-FDG and [15O]-water PET scans prior to NC. The FDG metabolic rate (MRFDG) and transport (FDG K1) parameters were calculated; blood flow (BF) was estimated from the water PET scan. Response to NC was determined from surgical specimens with pathologic complete response (pCR) defined as eradication of invasive tumor in the breast vs. other. Results: Of the tumors studied, 16 (31%) were TN, 30 (59%) were luminal, and 5 (10%) were HER2. pCR was observed in 4/16 (25%) TN tumors (95% CI: 0.10-0.50) compared to only 4/30 (13%) of luminal tumors (95% CI: 0.05-0.30) and 3/5 HER2 tumors. Linear regression of the association between PET parameters and phenotype (TN vs. luminal) found that TN was associated with higher MRFDG (p=0.007) and MRFDG/BF ratio (p=0.02), but not with BF (p=0.27). Only patients with low pre-therapy MRFDG/BF ratio (<35 umol/mL) achieved a pCR. Using this value as an ad-hoc cutoff, 4/7 (57%) of TN patients with low ratios had a pCR, while 0/9 with higher ratios had pCR. In contrast, only 4/21 (19%) of the luminal patients with low ratios had a pCR (one-sided mid-p=0.04 for TN vs. luminal pCR rate for patients with MRFDG/BF < 35 umol/mL). Discussion: These results demonstrate heterogeneity in breast tumor metabolism and perfusion as assessed by PET, and suggest a clinically relevant association between PET parameters and tumor phenotypes. The high MRFDG/BF ratio that predicts poor response to NC is more common in TN tumors; whereas in luminal or HER2 tumors, high MRFDG is generally matched with higher BF. Measurement of tumor metabolism and perfusion may identify a subset of tumors which are unlikely to respond to NC. Identification of such tumors may direct therapy toward those biologic targets most likely to overcome resistance.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6005.

Use of changes in blood flow PET measurements to predict post-therapy lymph node status among locally advanced breast cancer patients

575

Background: Response to neoadjuvant therapy in the primary tumor and nodal metastasis predicts benefit to patients as shown in several large clinical trials. We have previously shown that changes in tumor blood flow (BF) measured by [15O]-water PET predict pathologic primary tumor response. We now test whether primary tumor blood flow changes also predict axillary nodal metastases response and post-therapy lymph node status among women with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy. Methds: Fifty-five women with a primary diagnosis of LABC underwent dynamic [15O]-water PET scans prior to and at midpoint of neoadjuvant chemotherapy. We evaluated associations between tumor BF changes and pathologic primary tumor response: categorized as complete (CR), partial (PR) or no response (NR). We also assessed the relationship between primary tumor BF changes and post-therapy axillary lymph node status, categorizing the high risk (HR) group as 4+ nodes with extracapsular extension (ECE, n=12) versus the lower risk (LR) group with either fewer than 4+ nodes or without ECE (n=43). Results: The median changes in BF versus tumor response were: CR = -77%, PR = -40%, and, NR = +20% (P = <0.001). For axillary node response, the median BF change among HR patients was +20% versus - 49% among LR patients (P = 0.004). Eight of 17 patients with an increase in tumor blood flow were HR whereas 4/38 patients with decreased tumor blood flow were HR (P = 0.002). Conclusions: Change in primary tumor blood flow over the course of neoadjuvant chemotherapy predicts pathologic response to treatment with a substantial decrease observed among CRs. An increase in primary tumor BF with treatment portends significant residual primary tumor and a nearly 50% chance of very high-risk nodal disease post-therapy.

No significant financial relationships to disclose.

Tumor metabolism, blood flow changes, and prognosis by positron emission tomography: A prospective cohort of locally advanced breast cancer patients

506

Background: Breast cancer patients with locally advanced tumors receive preoperative chemotherapy to provide early systemic treatment and assess in-vivo tumor response. Positron emission tomography (PET) has been used to follow tumor response to therapy, as pathologic response is predictive of patient outcome. We evaluated the prognostic utility of serial quantitative PET tumor blood flow (BF) and metabolism measurements. Methods: Fifty-five women with a primary diagnosis of locally advanced breast carcinoma (LABC) underwent dynamic [18F]-FDG and [15O]-water PET scans prior to and at midpoint of neoadjuvant chemotherapy. The FDG metabolic rate (MRFDG), transport (K1), and flux (Ki) parameters were calculated, and tumor blood flow was estimated from the [15O]-water study. Associations between tumor BF and MRFDG measurements and disease-free survival (DFS) and overall survival (OS) were evaluated using the Cox proportional hazards model. Results: Patients that had an increase in BF and K1, from baseline to mid-therapy measurements, had elevated recurrence and mortality risks compared to patients that had reductions in BF and MRFDG values. In multivariate analysis, changes in BF and K1 remained independent prognostic indicators of DFS and OS survival. Conclusions: PET measurements of tumor response prior to completion of neoadjuvant chemotherapy were predictive of patient outcome. Patients that failed to have a decline in BF and K1 experienced higher risks of recurrence and mortality that was largely independent of clinical tumor characteristics assessed in this study. These results suggest that tumor perfusion, measured directly by [15O]-water or indirectly by dynamic FDG PET, is highly predictive of outcome in neoadjuvantly treated breast cancer.

No significant financial relationships to disclose.

Early experience with 'new federalism' in health insurance regulation

The authors monitored the implementation of the Health Insurance Portability and Accountability Act (HIPAA) from 1997 to 1999. Regulators in all states and relevant federal agencies were interviewed and applicable laws and regulations studied. The authors found that HIPAA changed legal protections for consumers' health coverage in several ways. They examine how the process of regulating such coverage was affected at the state and federal levels and under an emerging partnership of the two. Despite some early implementation challenges, HIPAA's successes have been significant, although limited by the law's incremental nature.

[Structure and quality of German-language gastroscopy information forms from the patients' viewpoint]

Information about procedure and risks is prerequisite for obtaining informed consent for endoscopy. This prospective and randomized investigation evaluated (i) the extent of patients' information needs and (ii) the formal quality (language, ease of understanding, length, figures etc.) of three information forms concerning upper CI-endoscopy issued in 1995 by DIOmed (1), perimed compliance (2), and PERIMED-spitta (3) as judged by the patients. (iii) Outcome quality was investigated as the influence of these forms on understanding why and how endoscopy was performed as well as the influence on feeling threatened. Furthermore patients' anxiety was assessed by using Spielberger's state-trait anxiety inventory (STAI). 218 patients completed the investigation (n = 73; 70; 75, respectively). 60% claimed the need for a detailed explanation of the planned endoscopy and 48% said they wanted exhaustive informations about potential complications and risks. The three forms (length 819, 771, 1,245 words) were entirely read by 87%, 89% and 82% of the patients. Positive language, adequate length (69%, 69%, 71%) and adequate layout were evenly attributed to the three forms. A high impact of the figures for understanding was found more frequently (48%, 46%, 35%) with (1) and (2) and language war regarded easy by 57%, 54% and 44%, respectively. Flesh's reading ease score, however, proved a sophisticated niveau of language with all three forms. The indication for endoscopy (37%, 49%, 56%) and explanation of performance (43%, 43%, 63%) was superior with (3). This form also reduced anxiety as judged by STAI-means, overall STAI-changes, and relevant changes (> or = 5 points). Form (2) increased patients' anxiety.

CONCLUSION

While the formal quality of all information forms is appreciated by patients both their reading ease score and figures should be improved. A significant reduction of anxiety can be achieved by appropriate selection of the information material.

Dendritic cells retrovirally transduced with a model antigen gene are therapeutically effective against established pulmonary metastases

Dendritic cells (DCs) are bone marrow-derived leukocytes that function as potent antigen presenting cells capable of initiating T cell-dependent responses from quiescent lymphocytes. DC pulsed with tumor-associated antigen (TAA) peptide or protein have recently been demonstrated to elicit antigen-specific protective antitumor immunity in a number of murine models. Transduction of DCs with TAA genes may allow stable, prolonged antigen expression as well as the potential for presentation of multiple, or unidentified, epitopes in association with major histocompatibility complex class I and/or class II molecules. To evaluate the potential efficacy of retrovirally transduced DCs, bone marrow cells harvested from BALB/c mice were transduced with either a model antigen gene encoding beta-galactosidase (beta-gal) or a control gene encoding rat HER-2/neu (Neu) by coculture with irradiated ecotropic retroviral producer lines. Bone marrow cells were differentiated into DC in vitro using granulocyte/macrophage colony-stimulating factor and interleukin-4. After 7 d in culture, cells were 45-78% double positive for DC phenotypic cell surface markers by FACS(R) analysis, and DC transduced with beta-gal were 41-72% positive for beta-gal expression by X-gal staining. In addition, coculture of beta-gal transduced DC with a beta-gal-specific T cell line (CTLx) resulted in the production of large amounts of interferon-gamma, demonstrating that transduced DCs could process and present endogenously expressed beta-gal. DC transduced with beta-gal and control rat HER-2/neu were then used to treat 3-d lung metastases in mice bearing an experimental murine tumor CT26.CL25, expressing the model antigen, beta-gal. Treatment with beta-gal-transduced DC significantly reduced the number of pulmonary metastatic nodules compared with treatment with Hank's balanced salt solution or DCs transduced with rat HER-2/neu. In addition, immunization with beta-gal-transduced DCs resulted in the generation of antigen-specific cytotoxic T lymphocytes (CTLs), which were significantly more reactive against relevant tumor targets than CTLs generated from mice immunized with DCs pulsed with the Ld-restricted beta-gal peptide. The results observed in this rapidly lethal tumor model suggest that DCs transduced with TAA may be a useful treatment modality in tumor immunotherapy.

Caregiving: concept analysis and outcomes

More than ever before, caregiving has become a salient public policy issue. A number of recent and anticipated demographic, economic and social changes have occurred that make it imperative for researchers to critically examine the impact of caregiving on family caregivers' health, behavior, emotions, and social status. Researchers at the University of Iowa College of Nursing are working to classify standardized nursing-sensitive patient outcomes for use in language development, practice, research, and education to evaluate the effectiveness of nursing interventions and clinical nursing services. This article focuses on family caregiving and the analysis of caregiver role performance in both direct and indirect care, linking outcomes and indicators, to enable nurses to promote the health of caregivers.

Genome duplication in soybean (Glycine subgenus soja)

Restriction fragment length polymorphism mapping data from nine populations (Glycine max x G. soja and G. max x G. max) of the Glycine subgenus soja genome led to the identification of many duplicated segments of the genome. Linkage groups contained up to 33 markers that were duplicated on other linkage groups. The size of homoeologous regions ranged from 1.5 to 106.4 cM, with an average size of 45.3 cM. We observed segments in the soybean genome that were present in as many as six copies with an average of 2.55 duplications per segment. The presence of nested duplications suggests that at least one of the original genomes may have undergone an additional round of tetraploidization. Tetraploidization, along with large internal duplications, accounts for the highly duplicated nature of the genome of the subgenus. Quantitative trait loci for seed protein and oil showed correspondence across homoeologous regions, suggesting that the genes or gene families contributing to seed composition have retained similar functions throughout the evolution of the chromosomes.

The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long-term care facility

Although concern for the costs associated with pressure ulcer treatments persists, studies that precisely quantify costs are limited. A retrospective research design was used to describe the costs incurred by an 830-bed, long-term care facility to treat 81 pressure ulcers over a one-year period following implementation of a research-based, skin care protocol. The total cost for the study period was $30,079 with 73% of these expenditures attributable to nursing care. Mean cost of treatment was $3.74/pressure ulcer/day, which was a reduction from the $5.35/pressure ulcer/day cost prior to implementation of the skin care protocol. These findings suggest that implementing a research-based, skin care protocol can promote a reduction in treatment costs.

Alzheimer's special care units

An overview of Alzheimer's special care units is provided, including the several models that have been used to guide their development. Philosophy and programming, physical and social environments, staff selection and training, admission and discharge criteria, family programming, and quality and cost features are described. Evaluation and research of special units and interventions for residents with Alzheimer's, their family members and staff caregivers are discussed.

Disseminated neoplastic cells in Mytilus trossulus: verification of host species origin by (16S-like) rRNA sequence comparison

Disseminated neoplasia is a leukemia-like disease that occurs in many species of bivalve molluscs worldwide, including the bay mussel (Mytilus trossulus). The etiology of the disease is undetermined, but an early report proposed that the anomalous bivalve cells were actually an invasive parasite rather than cancerous cells of host origin. Comparison of partial sequences of small subunit rRNA from normal and putative cancer cells was performed to resolve this issue. These studies showed a close phylogenetic relationship of the different forms of cancer cells to each other (similarity coefficient, 0.982), to the normal hemocytes (similarity coefficient, 0.990, 0.992), and to the oyster, Crassostrea virginica (similarity coefficient, 0.895-0.927). A large phylogenetic distance separates all 3 mussel hemocyte types from several representative protists (similarity coefficient, 0.702-0.761). These results indicate that the disseminated neoplastic cells in mussels are indeed proliferative host cells and not unicellular parasites.

Adoption of research-based practice for treatment of pressure ulcers in long-term care

Implementation of a clinical trial to evaluate the effectiveness of electrotherapy on pressure ulcer healing provided the stimulus for adoption of research-based innovations for pressure ulcer treatment in one long-term care facility. A five-year retrospective study conducted prior to introduction of the clinical trial revealed that 72 different treatments were applied to pressure ulcers. Forty-two percent of the pressure ulcers were left open to the air or covered with a dry gauze dressing and 64% were treated with some type of antiseptic solution. Since implementation of the clinical trial and the accompanying access to wound healing research knowledge it provided in this setting, the prevailing treatment for pressure ulcers has become moist physiologic dressings.

The cost of treating pressure ulcers in a long-term care facility

Although there is rising concern with the cost of pressure ulcer treatment, actual expenditures have not been quantified in many settings. A retrospective research design was used to describe the costs incurred by an 830-bed long-term care facility to treat 240 pressure ulcers over a five-year period. The total cost was $116,416 for the study period. The mean cost of treatment was $5.35/pressure ulcer/day. These costs are substantially lower than the costs of pressure ulcer treatment in acute care. Further study to compare treatment costs with prevention costs would provide useful information on the cost benefits of prevention.

Adjunct executive appointment for faculty. An innovation in nursing collaboration

The need for collaboration has never been greater. The healthcare delivery system faces unprecedented challenges arising from prospective payment, competition in the marketplace, higher patient acuity levels, and a shortage of professional nursing staff. The authors discuss a service-education collaboration model based on adjunct executive appointments of faculty members to healthcare organizations. The authors describe the model, a conceptual framework to guide its development, case studies of its implementation, and a summary of the benefits and risks associated with the initial implementation of the model.

The implementation of nursing diagnoses. The Iowa Veterans Home experience

This article has reviewed the process of implementing nursing diagnoses in one long-term care agency. Nursing diagnoses improved nursing process skills, made problem identification more accurate, and aided the identification of nursing interventions and desired outcomes. Nursing diagnoses have become the organizing framework for quality assurance, staff development, specialization and consultation, and computer applications. The presence of a professional model of nursing practice facilitated the use of nursing diagnoses. Prior to implementing nursing diagnoses, IVH nurses had defined the scope of nursing practice and formed a committee structure for decision-making by all RNs. The structure included mechanisms for collective and individual accountability. All nurses participated in the decision to use nursing diagnoses in their practice. Each nurse had the opportunity to influence the process of change. The process of implementing nursing diagnoses at IVH continues. Nurses recognize the need to establish the validity of each diagnostic statement. Skill with the diagnostic process is expected to improve. Nurses also recognize the need to test interventions for specific diagnoses. The standard nomenclature will continue to be used for the improvement of nursing practice and for nursing department programming. The use of nursing diagnoses is the basis of the continued development of a professional model of nursing practice.