The role of contrast-enhanced mammography in the preoperative evaluation of invasive lobular carcinoma of the breast

AIM

To assess the performance of contrast-enhanced mammography (CEM) in the preoperative staging of invasive lobular carcinoma (ILC) of the breast.

MATERIALS AND METHODS

The present study was a multicentre, multivendor, multinational retrospective study of women with a histological diagnosis of ILC who had undergone CEM from December 2013 to December 2021. Index lesion size and multifocality were recorded for two-dimensional (2D) mammography, CEM, and when available magnetic resonance imaging (MRI). Comparison with histological data was undertaken for women treated by primary surgical excision. Pearson correlation coefficients and Bland-Altman's analysis of agreement were used to assess differences with a significance level of 0.05.

RESULTS

One hundred and fifteen ILC lesions were included, 46 (40%) presented symptomatically and 69 were screening detected. CEM demonstrated superior sensitivity when compared to standard mammography. The correlation between the histological size measured on the surgical excision specimen size was greater than with standard mammography (r=0.626 and 0.295 respectively, p=0.001), with 19% of lobular carcinomas not visible without a contrast agent. The sensitivity of CEM for multifocal disease was greater than standard mammography (70% and 20% respectively, p<0.0001). CEM overestimated tumour size by an average of 1.5 times, with the size difference increasing for larger tumour. When MRI was performed (n=22), tumour size was also overestimated by an average of 1.3 times. The degree of size overestimation was similar for both techniques, with the tumour size on CEM being on average 0.5 cm larger than MRI.

CONCLUSION

CEM is a useful tool for the local staging of lobular carcinomas and could be an alternative to breast MRI.

Development and validation of a multivariable model for prediction of malignant transformation and recurrence of oral epithelial dysplasia

BACKGROUND

Oral epithelial dysplasia (OED) is the precursor to oral squamous cell carcinoma which is amongst the top ten cancers worldwide. Prognostic significance of conventional histological features in OED is not well established. Many additional histological abnormalities are seen in OED, but are insufficiently investigated, and have not been correlated to clinical outcomes.

METHODS

A digital quantitative analysis of epithelial cellularity, nuclear geometry, cytoplasm staining intensity and epithelial architecture/thickness is conducted on 75 OED whole-slide images (252 regions of interest) with feature-specific comparisons between grades and against non-dysplastic/control cases. Multivariable models were developed to evaluate prediction of OED recurrence and malignant transformation. The best performing models were externally validated on unseen cases pooled from four different centres (n = 121), of which 32% progressed to cancer, with an average transformation time of 45 months.

RESULTS

Grade-based differences were seen for cytoplasmic eosin, nuclear eccentricity, and circularity in basal epithelial cells of OED (p < 0.05). Nucleus circularity was associated with OED recurrence (p = 0.018) and epithelial perimeter associated with malignant transformation (p = 0.03). The developed model demonstrated superior predictive potential for malignant transformation (AUROC 0.77) and OED recurrence (AUROC 0.74) as compared with conventional WHO grading (AUROC 0.68 and 0.71, respectively). External validation supported the prognostic strength of this model.

CONCLUSIONS

This study supports a novel prognostic model which outperforms existing grading systems. Further studies are warranted to evaluate its significance for OED prognostication.

Impact of the COVID-19 pandemic on a post-mortem CT service for adult non-suspicious death

Due to the COVID-19 pandemic, the post-mortem computed tomography (PMCT) service was expanded from three to seven cases per day to help mortuary services and avoid invasive autopsy. Additional targeted angiography and pulmonary ventilation procedures were stopped and triage rules relaxed to allow more indications to be scanned, including those requiring toxicology. A service evaluation was performed for the first 3-months of the COVID-19 pandemic compared to the equivalent period the previous year to study the impact of these changes. It was found that, despite the increase in deaths regionally, coronial referrals remained about 100 per month, a reduction in referral rate. The number undergoing PMCT rose from 28% to 74% of cases. Turnaround time remained the same. For cases triaged to PMCT, the need for subsequent autopsy increased from 7.9% to 15.8%. No significant changes were seen in diagnosis rates, including cardiac or respiratory. There was an increase in patients with coronary death without severe coronary calcification who underwent autopsy after PMCT. These may have been diagnosed by targeted coronary angiography. Fifty-three cases requiring toxicology/biochemistry had PMCT, with 38 having PMCT only. In 8/11 (72.7%) cases with normal PMCT and toxicology as the key diagnostic test, autopsy was performed prior to results. This suggests the pathology team were reluctant to risk an "unascertained" outcome. This study shows that it is possible to increase PMCT services by widening referral criteria and by limiting the use of enhanced imaging techniques, without significantly changing diagnosis rates of key diseases; however, selectively restarting targeted angiography may help avoid autopsy in some cases.

Arfid Genes and Environment (ARFID-GEN): Study Protocol

Background

The Avoidant Restrictive Food Intake Disorder Genes and Environment (ARFID-GEN) study is a study of genetic and environmental factors that contribute to risk for developing ARFID in children and adults.

Methods

A total of 3,000 children and adults with ARFID from the United States will be included. Parents/guardians and their children with ARFID (ages 7 to 17) and adults with ARFID (ages 18+) will complete comprehensive online consent, parent verification of child assent (when applicable), and phenotyping. Enrolled participants with ARFID will submit a saliva sample for genotyping. A genome-wide association study of ARFID will be conducted.

Discussion

ARFID-GEN, a large-scale genetic study of ARFID, is designed to rapidly advance the study of the genetics of eating disorders. We will explicate the genetic architecture of ARFID relative to other eating disorders and to other psychiatric, neurodevelopmental, and metabolic disorders and traits. Our goal is for ARFID to deliver "actionable" findings that can be transformed into clinically meaningful insights.

Trial registration

ARFID-GEN is a registered clinical trial: clinicaltrials.gov NCT05605067.

Long COVID prevalence and associated characteristics among a South Alabama population

OBJECTIVES

Long COVID can significantly impact a patient's quality of life. Defined as persistence or emergence of symptoms 4+ weeks after initial COVID-19 diagnosis, long COVID can result in functional impairments, pulmonary issues, and neuropsychiatric conditions, among others. This study aims to identify long COVID risk factors and prevalence in a south Alabama (US) patient population.

STUDY DESIGN

This was a longitudinal cohort study.

METHODS

Postdiagnosis standardized phone interviews (baseline, 6 months, and 12 months) from April 2020 to July 2021 with patients testing positive through a large healthcare system. Interviews gathered data on sociodemographics, comorbidities, acute illness, and long COVID. Relationships between 1+ ongoing symptoms and variables of interest were assessed using a generalized estimating equation to conduct multivariate analysis.

RESULTS

Of the 516 participants, most were female (65%) and African American (57%, n = 293), with a median (interquartile range) age of 41.1 (25.3-54.6) years. Retention was 70% (n = 359) at 6 months and 58% (n = 301) at 12 months. Participants reporting 1+ persistent symptoms were 20% and 17% at 6 and 12 months, respectively. Illness severity (P < 0.0001) and COVID-related emergency room visit with hospital admission at the time of diagnosis (P = 0.0018) were significantly associated with increased long COVID risk.

CONCLUSIONS

This study found substantial rates of long COVID within our population, with stable rates at 6 and 12 months, indicating illness persistence. Our findings support growing concern for long COVID as a persistent issue within the medical community, with potential to impact patient health for years. Larger, more uniform studies are required to further characterize disease risk factors and clinical course to inform the disease management.

Technical note on the exploration of COVID-19 in autopsy material

Interrogation of immune response in autopsy material from patients with SARS-CoV-2 is potentially significant. We aim to describe a validated protocol for the exploration of the molecular physiopathology of SARS-CoV-2 pulmonary disease using multiplex immunofluorescence (mIF).The application of validated assays for the detection of SARS-CoV-2 in tissues, originally developed in our laboratory in the context of oncology, was used to map the topography and complexity of the adaptive immune response at protein and mRNA levels.SARS-CoV-2 is detectable in situ by protein or mRNA, with a sensitivity that could be in part related to disease stage. In formalin-fixed, paraffin-embedded pneumonia material, multiplex immunofluorescent panels are robust, reliable and quantifiable and can detect topographic variations in inflammation related to pathological processes.Clinical autopsies have relevance in understanding diseases of unknown/complex pathophysiology. In particular, autopsy materials are suitable for the detection of SARS-CoV-2 and for the topographic description of the complex tissue-based immune response using mIF.

Abstract A23: True-T – Improved prediction by holistic artificial intelligence-based quantification of T-cell response

Introduction - Seminal work from Galon et al [PMID: 16371631], found immunohistochemical (IHC) quantification of the immune response to be prognostic in colorectal cancer (CRC). Although numerous systems for scoring T-cell subsets have been published [reviewed in PMID: 35758208] and this type of scoring is acknowledged as a bona fide diagnostic test [PMID: 32320495], it is not commonly used in general diagnostic routine. Our group reported recently that a digital pathology (DP) approach to scoring of CD3/CD4/CD8 in more than 1,500 patients was prognostic of survival in CRC Stage II & III and predictive of chemotherapy response in CRC Stage IV [PMID: 32684627]Hypothesis – An artificial intelligence (AI)-based approach to DP analysis of CD3/CD4/CD8 provides unbiased prognostic and predictive advantage in CRC.Materials & Methods - 3,123 whole slide images from 1,041 patient samples from 4 institutions in the context of the PathLAKE UK DP Consortium (Queens’s University Belfast, University of Oxford, University of Nottingham and University Hospital Coventry and Warwick). These samples represented 4 different clones [LN10 (CD3), 4B12 (CD4), 4B11 (CD8) and SP3 (CD4)] from 3 different companies, and were scanned with the Aperio AT2 scanner. Ninety-six experiments for validation and verification were carried out with open-source AI systems following protocols and pathways described before [PMID: 35626427 & PMID: 34359723].Results – We developed a combined CD3/CD4/CD8 AI scoring tool (True-T) which can quantify CD3/CD4/CD8 expressing cells with an accuracy ranging between 96.94 and 99.26; a sensitivity range of 79.27 to 85.22 and a specificity of 98.96 to 99.40. Using this novel AI method of immune cell classification, previous study findings were replicated across four UK centers using an independent cohort of CRC patients using antibody clones optimized for routine clinical diagnostics (p=0.002; HR: 2.21; 95%CI:1.24-3.94 versus p=0.006; hr: 1.84; 95% ci: 1.54-2.21 in the current and former study [PMID: 32684627] respectively). We now have integrated True-T status into a easy to use graphical user interface (GUI), which includes key determinants of CRC prognosis from within a population-representative cohort (n&gt;600), in order to be able to model the impact of a high or low True-T score with other variables of clinical significance.Conclusion – True-T shows that a holistic AI-based quantification of T-cell response potentially improves prediction of patient prognosis over other in-silico quantitative methods in CRC and can be implemented in routine diagnostics in a seamless manner with an easy-to-use GUI.

Citation Format: Manuel Salto-Tellez, Yasmine Makhlouf, Stephanie Craig, Paul O'Reilly, Perry Maxwell, Jacqueline James. True-T – Improved prediction by holistic artificial intelligence-based quantification of T-cell response [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy; 2022 Oct 21-24; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(12 Suppl):Abstract nr A23.

'Breast Cosmesis After Breast-Conserving Therapy' Who is the Judge, Patient or Surgeon?

INTRODUCTION

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts-this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient's perception.

METHOD

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen's kappa was calculated to define the strength of the inter-rater agreement.

RESULTS

One hundred twelve patients with a mean age of 59 (range 27-89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions 'How your lumpectomy breast looks?' and 'How you look in the mirror unclothed?' respectively (Cohen's k = 0.464, 95% CI 0.337-0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen's k = 0.172, 95% CI - 0.020-2.093, p = 0.067).

CONCLUSION

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

393 Communication in Catheter Care: A Closed Loop Audit of Catheter Documentation in Emergency Presentations to a Tertiary Urology Centre

Aim

Estimates suggest that 20% of patients admitted to hospital undergo catheterisation, some of whom will end up discharged with catheters. Clear documentation assists in communication between hospital and community teams. The EAUN has identified key areas for documentation including use of care plans. We audited compliance with documentation pre- and post-intervention in a tertiary urology department

Method

Emergency patients presenting to urology were identified over a 3-week period pre-intervention and 3-weeks post-intervention. Clinical notes were audited for documentation of catheterisation. Domains assessed included indication, type/size of catheter, catheter balloon volume, residual volume, urinalysis, and plan. Use of care plans was also audited. Intervention involved development and deployment of a poster as well as discussion with staff.

Results

In total 274 patients were identified. 47 catheters were inserted pre-intervention, with variable compliance in documentation throughout the domains with similar pattern of compliance noted in the post-intervention group (n=42). Compliance was highest in size of catheter and indication for insertion, with urinalysis the most frequently missed domain (14.9% pre-intervention, 9.5% post-intervention). The only area with significant improvement was documentation of balloon volume (p=0.0019). Use of the care plan showed some minor improvement but was generally poor.

Conclusion

Use of visual cues did not result in approvement in documentation. Discussion with the teams suggested awareness of the domains and care plan however, they didn't necessarily think of them at time of documentation. As such a text prompt for the electronic notes is now in development and further audit to assess impact pending.

Levetiracetam-induced gingival hyperplasia

Levetiracetam is a new generation antiseizure medication which binds to synaptic vesicle protein SV2A and inhibits the release of neurotransmitters. Gingival hyperplasia is a common side effect of conventional antiseizure medications like phenytoin, but very rare with the newer ones. A 14-year-old boy was started on levetiracetam 250 mg twice daily after a generalized seizure. Five days later he presented with gingival swelling and painful oral aphthae, without lymphadenopathy or systemic symptoms. Blood investigations were normal. After one-month of stopping the drug, the lesions cleared. This case highlights the importance of maintaining good oral hygiene and periodic dental review in patients on antiseizure medications.

Which lesions with a radiological or core biopsy diagnosis of fibroadenoma should be excised?

INTRODUCTION

A recent Association of Breast Surgery summary statement on fibroadenoma management recommends excision only for cellular fibroepithelial lesions and rapidly growing lesions with a core biopsy diagnosis of fibroadenoma; persistent pain is a relative indication for excision.

METHODS

This retrospective study looked at the impact this approach would have on the diagnosis of phyllodes tumours.

RESULTS

From 2014 to 2018, there were 1,058 core biopsy diagnoses of fibroadenoma; 112 lesions were excised, of which 98 were fibroadenomas, 4 were hamartomas and 10 were phyllodes tumours. In this group, an excision diagnosis of phyllodes tumour was associated with size more than 40 mm, age more than 40 years and radiological suspicion of phyllodes tumour or carcinoma. One hundred and sixty-six excised fibroepithelial lesions with no previous core biopsy included eight phyllodes tumours; in this group, rapid growth was associated with phyllodes tumour diagnosis. Twelve of the 26 fibroepithelial lesions classified as B3 (cellular fibroepithelial lesion or phyllodes tumour) were diagnosed as phyllodes tumours on excision. Using a combination of radiological, clinical and pathological features it was possible to create an excision policy that would recommend excision of 22 of the 31 phyllodes tumours in this period. Eight of the nine 'missed' phyllodes tumours were benign.

CONCLUSION

The Association of Breast Surgery summary statement will reduce the number of fibroadenomas excised, but may also result in delayed diagnosis of some phyllodes tumours. Appropriate safety netting advice should be provided to identify rapidly growing lesions.

1328 A Risk Stratified Post-Nephrectomy Surveillance Protocol – 5-Year Assessment of Performance

Introduction

Recurrence rate of surgically treated localised renal cell carcinoma (RCC) is reported to be approximately 20%. There is lack of consensus on the optimal surveillance regimen. We assess the performance of our surveillance protocol based upon prognostic histological factors. We report the outcome of our first cohort to reach 5 years follow up.

Method

A retrospective analysis was performed of patients who underwent a radical or partial nephrectomy between March 2014 and October 2015. Patients were classified as high, intermediate, or low risk based on pathology; with each group undergoing individualised radiological follow up.

Results

80 patients with pathologically confirmed RCC who underwent partial or radical nephrectomy were identified. Recurrence was noted in 24% (n = 19), and a third of those patients (n = 7) died within the 5-year follow-up period. 79% (n = 15) of patients with recurrence were of intermediate or high-risk group. 90% of recurrences were picked up on surveillance scans, 5% due to symptoms related to the recurrence and 5% incidentally. 70% occurred within the first 2 years post-surgery. 92% (n = 6) of those who died had an ASA of 2 or higher. In the whole cohort, total number of deaths was 13. 38% (n = 5) died of RCC, 54% (n = 7) died of other causes and in 8% (n = 1) cause of death of was unclear.

Conclusions

Our risk stratified surveillance protocol identified 90% of recurrences within the 5-year follow-up. Future refinement of our protocol could include an assessment of performance status which may influence the schedule of radiological surveillance.

Opportunities in cancer imaging: risk-adapted breast imaging in screening

In the UK, women between 50-70 years are invited for 3-yearly mammography screening irrespective of their likelihood of developing breast cancer. The only risk adaption is for women with >30% lifetime risk who are offered annual magnetic resonance imaging (MRI) and mammography, and annual mammography for some moderate-risk women. Using questionnaires, breast density, and polygenic risk scores, it is possible to stratify the population into the lowest 20% risk, who will develop <4% of cancers and the top 4%, who will develop 18% of cancers. Mammography is a good screening test but has low sensitivity of 60% in the 9% of women with the highest category of breast density (BIRADS D) who have a 2.5- to fourfold breast cancer risk. There is evidence that adding ultrasound to the screening mammogram can increase the cancer detection rate and reduce advanced stage interval and next round cancers. Similarly, alternative tests such as contrast-enhanced mammography (CESM) or abbreviated MRI (ABB-MRI) are much more effective in detecting cancer in women with dense breasts. Scintimammography has been shown to be a viable alternative for dense breasts or for follow-up in those with a personal history of breast cancer and scarring as result of treatment. For supplemental screening to be worthwhile in these women, new technologies need to reduce the number of stage II cancers and be cost effective when tested in large scale trials. This article reviews the evidence for supplemental imaging and examines whether a risk-stratified approach is feasible.

Complications of combination intranasal corticosteroids and anti-retroviral therapy

BACKGROUND

Intranasal corticosteroids are widely used for management of many upper airway diseases because of their ability to effectively deliver local relief of inflammation.

CASE REPORT

This paper presents the case of a 51-year-old man with human immunodeficiency virus treated with ritonavir who was started on fluticasone intranasal spray for presumed chronic rhinosinusitis. Months after starting this therapy, he developed symptoms of Cushing's syndrome and avascular necrosis of the shoulder due to the pharmacological interactions between fluticasone and ritonavir.

CONCLUSION

Although intranasal corticosteroids are deemed a low-risk route of drug administration, clinicians need to be vigilant in appropriately prescribing corticosteroids in the setting of drug potentiators, particularly in these high-risk patients. Alternative corticosteroids such as beclomethasone dipropionate should be considered in such cases.

Lime activated flyash-phosphogypsum blend as a low-cost alternative binder

This study investigates the potential of a blended binder formulated from two industrial solid wastes viz. phosphogypsum and fly ash in combination with lime. Three mix proportions of phosphogypsum and fly ash were investigated, and the minimum lime contents required for activation were determined using the Eades and Grim pH test. The lime-fly ash-phosphogypsum blends were then cast into cubes, both in their paste form as well as mortar form, mixed with sand in the ratio of 1:3. They were cured for a period of seven days, and afterwards, their compressive strength was determined. Ordinary Portland cement and lime mortar blocks were also cast as control specimens for comparative evaluation of the strength. The optimal lime-fly ash-phosphogypsum blend was identified and used to construct a masonry prism, and the strengths of the masonry prisms were also evaluated. The optimal lime-fly ash-phosphogypsum blend mortar was also subjected to an X-ray diffraction analysis to determine the reaction products formed during hydration. The study revealed that 5% lime mixed with fly ash:phosphogypsum in the ratio of 3:1 was the optimal proportion which gave the maximum strength to the cubes. The optimal lime-fly ash-phosphogypsum blend mortar developed strength that was higher than conventional Portland cement and lime mortar. The optimal lime-fly ash-phosphogypsum blend mortar masonry prisms developed strength that was comparable to that of Portland cement mortar masonry. The X-ray diffraction analysis revealed the formation of calcium silicate hydrate minerals as well as ettringite and portlandite which were responsible for strength gain.

The Potential of Digital Image Analysis to Determine Tumor Cell Content in Biobanked Formalin-Fixed, Paraffin-Embedded Tissue Samples

Introduction: Best practices dictate that biobanks ensure accurate determination of tumor content before supplying formalin-fixed, paraffin-embedded (FFPE) tissue samples to researchers for nucleic acid extraction and downstream molecular testing. It is advisable that trained and competent individuals, who understand the requirements of the downstream molecular tests, perform the microscopic morphological examination. However, the special skills, time, and costs associated with these assessments can be prohibitive, especially in large case cohorts requiring extensive pathological review. Determination of tumor content reliably by digital image analysis (DIA) could represent a significant advantage if validated, utilized, and deployed by biobanks. Materials and Methods: Whole slide digital scanned images of colorectal, lung, and breast cancer specimens were created. The scanned images were imported into the DIA software QuPath and digital annotations were completed by biobank technicians, under the direction of trained histopathology senior scientists. Automated cell detection was conducted and tumor epithelial cells were classified and quantified. Results: DIA scores were highly concordant with the manual assessment for 376 of 435 samples (86%). A detailed review of discordant cases indicated digital scores had a higher accuracy than the manual estimation. Conclusion: Automated digital quantification has the potential to replace visual estimations with reduced subjectivity and increased reliability compared with manual tumor estimations. We recommend the use of DIA by biobanks involved in provision of FFPE tissue samples, especially in large research studies requiring high volumes of cases to be analyzed.

Highly pathogenic avian influenza virus H5N6 (clade 2.3.4.4b) has a preferable host tropism for waterfowl reflected in its inefficient transmission to terrestrial poultry

Highly-pathogenic avian influenza virus (HPAIV) H5N6 (clade 2.3.4.4b) incurred into Europe in late 2017 and was predominantly detected in wild birds, with very few terrestrial poultry cases. Pekin ducks directly-infected with a UK virus (H5N6-2017) were donors of infection to investigate contact transmission to three recipient species: Ducks, chickens and turkeys. H5N6-2017 transmission to ducks was 100% efficient, but transmission to in-contact galliforme species was infrequent and unpredictable, thereby reflecting the European 2017-2018 H5N6 epidemiology. Although only two of 28 (7%) infected ducks died, the six turkeys and one chicken which became infected all died and displayed systemic H5N6-2017 dissemination, while pathogenesis in ducks was generally milder. Analysis of H5N6-2017 progeny in the contacts revealed no emergent polymorphisms in an infected duck, but the galliforme species included changes in the polymerase (PB2 A199T, PA D347A), matrix (M1 T218A) and neuraminidase genes (T88I). H5N6-2017 environmental contamination was associated with duck shedding.

PD-L1 Multiplex and Quantitative Image Analysis for Molecular Diagnostics

Multiplex immunofluorescence (mIF) and digital image analysis (DIA) have transformed the ability to analyse multiple biomarkers. We aimed to validate a clinical workflow for quantifying PD-L1 in non-small cell lung cancer (NSCLC). NSCLC samples were stained with a validated mIF panel. Immunohistochemistry (IHC) was conducted and mIF slides were scanned on an Akoya Vectra Polaris. Scans underwent DIA using QuPath. Single channel immunofluorescence was concordant with single-plex IHC. DIA facilitated quantification of cell types expressing single or multiple phenotypic markers. Considerations for analysis included classifier accuracy, macrophage infiltration, spurious staining, threshold sensitivity by DIA, sensitivity of cell identification in the mIF. Alternative sequential detection of biomarkers by DIA potentially impacted final score. Strong concordance was observed between 3,3'-Diaminobenzidine (DAB) IHC slides and mIF slides (R2 = 0.7323). Comparatively, DIA on DAB IHC was seen to overestimate the PD-L1 score more frequently than on mIF slides. Overall, concordance between DIA on DAB IHC slides and mIF slides was 95%. DIA of mIF slides is rapid, highly comparable to DIA on DAB IHC slides, and enables comprehensive extraction of phenotypic data and specific microenvironmental detail intrinsic to the sample. Exploration of the clinical relevance of mIF in the context of immunotherapy treated cases is warranted.

Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group

People with diabetes account for nearly one-fifth of all inpatients in English and Welsh hospitals; of these, up to 90% are admitted as an emergency. Most are admitted for a reason other than diabetes with only 8% requiring admission for a diabetes-specific cause. Healthcare professionals working in emergency departments experience numerous clinical challenges, notwithstanding the need to know whether each individual with diabetes requires urgent admission. This document has been developed and written by experts in the field, and reviewed by the parent organizations of the Joint British Diabetes Societies for Inpatient Care-Diabetes UK, the Diabetes Inpatient Specialist Nurse Group and the Association of British Clinical Diabetologists. The document aims to support staff working in emergency departments and elsewhere by offering practical advice and tools for effective, appropriate and safe triage. Each section relates to the commonest diabetic specific emergencies and algorithms can be printed off to enable ease of access and use.

Schedule feasibility and workflow for additive manufacturing of titanium plates for ranioplasty in canine skull tumors

Background

Additive manufacturing has allowed for the creation of a patient-specific custom solution that can resolve many of the limitations previously reported for canine cranioplasty. The purpose of this pilot study was to determine the schedule feasibility and workflow in manufacturing patient-specific titanium implants for canines undergoing cranioplasty immediately following craniectomy.

Results

Computed tomography scans from patients with tumors of the skull were considered and 3 cases were selected. Images were imported into a DICOM image processing software and tumor margins were determined based on agreement between a board-certified veterinary radiologist and veterinary surgical oncologist. Virtual surgical planning was performed and a bone safety margin was selected. A defect was created to simulate the planned intraoperative defect. Stereolithography format files of the skulls were then imported into a plate design software. In collaboration with a medical solution centre, a custom titanium plate was designed with the input of an applications engineer and veterinary surgery oncologist. Plates were printed in titanium and post-processed at the solution centre. Total planning time was approximately 2 h with a manufacturing time of 2 weeks.

Conclusions

Based on the findings of this study, with access to an advanced 3D metal printing medical solution centre that can provide advanced software and printing, patient-specific additive manufactured titanium implants can be planned, created, processed, shipped and sterilized for patient use within a 3-week turnaround.

OP0167 SUCCESSFUL WITHDRAWAL OF MYCOPHENOLATE MOFETIL IN QUIESCENT SLE: RESULTS FROM A RANDOMIZED TRIAL

Background:

Trials and clinical observations have demonstrated the efficacy of mycophenolate mofetil (MMF) for SLE treatment. Long-term use of MMF is associated with adverse events, pregnancy risks, drug monitoring, and increased cost. Current management continues therapy indefinitely. Whether immunosuppression may be safely withdrawn or whether risks of withdrawal outweigh the benefits of continuation is unknown.

Objectives:

To compare rates of clinically significant disease reactivation (CSDR), major flares, and all flares in patients with quiescent SLE on stable MMF randomized to maintain or withdraw MMF. The goal is to provide guidance for clinicians and patients on the risks of MMF withdrawal.

Methods:

Adults with quiescent SLE (SELENA-SLEDAI without serologies <4) receiving MMF for ≥2 years for nephritis or ≥ 1 year for non-nephritis were randomized 1:1 to unblinded MMF (maintenance arm, MA) or to a 12-week taper off MMF (withdrawal arm, WA) and followed through 60 weeks. Subjects were on stable hydroxychloroquine; steroids limited to ≤ 10 mg. CSDR, defined as a SLEDAI flare requiring immunosuppression, BILAG flares and adverse events were assessed. Event rates and time to flare were compared using Kaplan-Meier.

Results:

102 subjects were randomized (50 MA, 52 WA); 1 subject in each arm was ineligible and 10 terminated early (7 MA, 3 WA). Mean disease duration was 13 years; 76% had a history of nephritis; mean baseline SLEDAI was 2.2. 5 MA subjects (10%) had CSDR, compared to 9 WA (17%). Median time to CDSR was 38 weeks in both arms. BILAG A flares occurred in 1MA subject (pancreatitis) vs. 4 WA (cranial neuropathy, panniculitis, 2 nephritis). Kaplan-Meier curves overlapped for CDSR, BILAG A flares, and all SLEDAI flares (Figure). Based on these data, we are 86% confident that the increased risk of CDSR with MMF withdrawal is less than 15% over 60 weeks. AEs were similar between groups; infections occurred more commonly in MA (63 vs. 49).

Conclusion:

In this cohort of subjects with quiescent SLE on long term MMF serious flares occurred infrequently in subjects continuing or withdrawing MMF without differences in time to flare. MMF withdrawal may be considered in subjects with prolonged quiescent disease.

Table 1.

Baseline and Demographic Characteristics

Maintenance armWithdrawal armTotalRandomized5052102Female, n (%)39 (78)47 (90)86 (84)White, n (%)25 (50)19 (37)44 (43)Black, n (%)19 (38)22 (42)41 (40)Hispanic/Latino, n (%)10 (20)12 (23)22 (22)Age, Years, mean (SD)42.4 (12.9)41.6 (12.5)42.0 (12.6)Disease Duration, Years, mean (SD)13.6 (8.2)12.2 (7.9)12.9 (8.0)H/O Lupus Nephritis, n (%)40 (80)38 (73)78 (76.5)On Baseline Steroids, n (%)18 (36)23 (44)41 (40)Prednisone Dose, mg, mean (SD)4.8 (2.7)3.3 (1.7)4.0 (2.3)MMF Duration, Years, mean (SD)6.8 (4.3)6.4 (4.3)6.6 (4.3)Baseline MMF Dose, mg, mean1,6121,6681,640SELENA-SLEDAI*, mean (SD)2.4 (1.76)1.9 (1.76)2.2 (1.77)Positive DsDNA, n (%)35 (70)27 (52)62 (61)Low C31, n (%)14 (28)9 (17)23 (23)Low C41, n (%)6 (12)5 (10)11 (11)Figure.

Kaplan-Meier Estimates of Flare Endpoints

Disclosure of Interests:

Eliza Chakravarty: None declared, Tammy Utset: None declared, Diane L Kamen Consultant of: Consulted on SLE survey development for Lilly and consulted on SLE trial protocol development for EMD Serono in 2019, Gabriel Contreras Grant/research support from: Genentech, Merck, Consultant of: Genentech, Merck, William Joseph McCune: None declared, Kenneth C Kalunian: None declared, Cynthia Aranow: None declared, Megan Clowse Grant/research support from: GSK, Pfizer, Consultant of: UCB, Astra-Zeneca, Speakers bureau: UCB, Ellen Goldmuntz: None declared, Jessica Springer: None declared, Lynette Keyes-Elstein: None declared, Bill Barry: None declared, Ashley Pinckney: None declared, Judith James: None declared

The adaptive immune and immune checkpoint landscape of neoadjuvant treated esophageal adenocarcinoma using digital pathology quantitation

BACKGROUND

Limited studies examine the immune landscape in Esophageal Adenocarcinoma (EAC). We aim to identify novel associations, which may inform immunotherapy treatment stratification.

METHODS

Three hundred twenty-nine EAC cases were available in Tissue Microarrays (TMA) format. A discovery cohort of 166 EAC cases were stained immunohistochemically for range of adaptive immune (CD3, CD4, CD8 and CD45RO) and immune checkpoint biomarkers (ICOS, IDO-1, PD-L1, PD-1). A validation cohort of 163 EAC cases was also accessed. A digital pathology analysis approach was used to quantify biomarker density.

RESULTS

CD3, CD4, CD8, CD45RO, ICOS and PD-1 were individually predictive of better overall survival (OS) (Log rank p = < 0.001; p = 0.014; p = 0.001; p = < 0.001; p = 0.008 and p = 0.026 respectively). Correlation and multivariate analysis identified high CD45RO/ICOS patients with significantly improved OS which was independently prognostic (HR = 0.445, (0.223-0.886), p = 0.021). Assessment of CD45RO and ICOS high cases in the validation cohort revealed an associated with improved OS (HR = 0.601 (0.363-0.996), p = 0.048). Multiplex IHC identified cellular co-expression of high CD45RO/ICOS. High CD45RO/ICOS patients have significantly improved OS.

CONCLUSIONS

Multiplexing identifies true cellular co-expression. These data demonstrate that co-expression of immune biomarkers are associated with better outcome in EAC and may provide evidence for immunotherapy treatment stratification.

Improving the Diagnostic Accuracy of the PD-L1 Test with Image Analysis and Multiplex Hybridization

Targeting of the programmed cell death protein (PD-1)/programmed death-ligand 1 (PD-L1) axis with checkpoint inhibitors has changed clinical practice in non-small cell lung cancer (NSCLC). However, clinical assessment remains complex and ambiguous. We aim to assess whether digital image analysis (DIA) and multiplex immunofluorescence can improve the accuracy of PD-L1 diagnostic testing. A clinical cohort of routine NSCLC patients reflex tested for PD-L1 (SP263) immunohistochemistry (IHC), was assessed using DIA. Samples of varying assessment difficulty were assessed by multiplex immunofluorescence. Sensitivity, specificity, and concordance was evaluated between manual diagnostic evaluation and DIA for chromogenic and multiplex IHC. PD-L1 expression by DIA showed significant concordance (R² = 0.8248) to manual assessment. Sensitivity and specificity was 86.8% and 91.4%, respectively. Evaluation of DIA scores revealed 96.8% concordance to manual assessment. Multiplexing enabled PD-L1+/CD68+ macrophages to be readily identified within PD-L1+/cytokeratin+ or PD-L1-/cytokeratin+ tumor nests. Assessment of multiplex vs. chromogenic IHC had a sensitivity and specificity of 97.8% and 91.8%, respectively. Deployment of DIA for PD-L1 diagnostic assessment is an accurate process of case triage. Multiplex immunofluorescence provided higher confidence in PD-L1 assessment and could be offered for challenging cases by centers with appropriate expertise and specialist equipment.

MAPKAPK2 (MK2) inhibition mediates radiation-induced inflammatory cytokine production and tumor growth in head and neck squamous cell carcinoma

Radiation therapy (RT) is a cornerstone of treatment in the management of head and neck squamous cell carcinomas (HNSCC), yet treatment failure and disease recurrence are common. The p38/MK2 pathway is activated in response to cellular stressors, including radiation, and promotes tumor inflammation in a variety of cancers. We investigated MK2 pathway activation in HNSCC and the interaction of MK2 and RT in vitro and in vivo. We used a combination of an oropharyngeal SCC tissue microarray, HNSCC cell lines and patient-derived xenograft (PDX) tumor models to study the effect of RT on MK2 pathway activation and to determine how inhibition of MK2 by pharmacologic (PF-3644022) and genetic (siRNA) methods impacts tumor growth. We show that high phosphorylated MK2 (p-MK2) levels are associated with worsened disease specific survival in p16-negative HNSCC patients. RT increased p-MK2 in both p16-positive, HPV-positive and p16-negative, HPV-negative HNSCC cell lines. Pharmacologic inhibition or gene silencing of MK2 in vitro abrogated RT-induced increases in p-MK2; inflammatory cytokine expression and expression of the downstream MK2 target, heat shock protein 27 (HSP27); and markers of epithelial-to-mesenchymal transition. Mouse PDX models treated with a combination of RT and MK2 inhibitor experienced decreased tumor growth and increased survival. Our results suggest that MK2 is a potential prognostic biomarker for head and neck cancer and that MK2 pathway activation can mediate radiation resistance in HNSCC.

A digital pathology demonstration of an "immune hot" ICOS+/CD45RO+ immunephenotype and the impact on survival in patients with esophageal adenocarcinoma

4062

Background: Therapies targeting immune checkpoints are changing our understanding of the biology and treatment of cancer. Analysing the immune landscape in esophageal adenocarcinoma (EA) may help future prognostication and therapeutic decision-making. Methods: We assembled 310 EA cases in a tissue microarray format with associated clinicopathological information, including a discovery cohort of 156 EA from Northern Ireland and a 154 EA validation cohort from Aberdeen. We carried out validated immunohistochemistry (IHC), stained for range of adaptive immune (CD3, CD4, CD8 and CD45RO) and immune checkpoint biomarkers (ICOS and IDO-1). Slides were digitised and assessed using QuPath image analysis software program to quantify their expression and correlate them with outcome. Results: In the discovery cohort we identified a group of patients highly expressing several immune biomarkers, conferring a significant positive survival advantage (p = 0.022). CD3, CD4, CD8, CD45RO, and ICOS were individually prognostic for better overall survival (Log rank p = 0.0003; p = 0.0292; p = 0.0015; p = 0.0008; p = 0.0051 and p = 0.0264 respectively). Multivariate and correlation analysis identified a subgroup of CD45RO+/ICOS+ patients with significantly improved overall survival (p = 0.0002). The co-expression of CD45RO+/ICOS+ immunophenotype was investigated in the validation cohort and a confirmed survival advantage was seen (p = 0.042). Additionally, the Opal Multiplex IHC technology revealed the much higher frequency of single-cell, dual labelling of CD45RO+/ICOS+ in immune hot cases. Conclusions: These data demonstrate the advantage of immune markers other than the traditional CD3/CD4/CD8 in EA prognostication. The fact that one of these biomarkers is an immune checkpoint inhibitor may have therapeutic implications.

Quality assurance guidance for scoring and reporting for pathologists and laboratories undertaking clinical trial work

While pathologists have always played a pivotal role in clinical trials ensuring accurate diagnosis and staging, pathology data from prognostic and predictive tests are increasingly being used to enrol, stratify and randomise patients to experimental treatments. The use of pathological parameters as primary and secondary outcome measures, either as standalone classifiers or in combination with clinical data, is also becoming more common. Moreover, reporting of estimates of residual disease, termed 'pathological complete response', have been incorporated into neoadjuvant clinical trials. Pathologists have the expertise to deliver this essential information and they also understand the requirements and limitations of laboratory testing. Quality assurance of pathology-derived data builds confidence around trial-specific findings and is necessarily focused on the reproducibility of pathological data, including 'estimates of uncertainty of measurement', emphasising the importance of pathologist education, training, calibration and demonstration of satisfactory inter-observer agreement. There are also opportunities to validate objective image analysis tools alongside conventional histological assessments. The ever-expanding portfolio of clinical trials will demand more pathologist engagement to deliver the reliable evidence-base required for new treatments. We provide guidance for quality assurance of pathology scoring and reporting in clinical trials.

High PTGS2 expression in post-neoadjuvant chemotherapy-treated oesophageal adenocarcinoma is associated with improved survival: a population-based cohort study

AIMS

High prostaglandin endoperoxide synthase-2 (PTGS2) enzyme expression in oesophageal adenocarcinoma has been shown to independently predict poor prognosis; however, the evidence is inconsistent. The aim of this study was to investigated the association between PTGS2 expression and prognosis in patients with oesophageal adenocarcinoma.

METHODS AND RESULTS

A cohort of 135 patients with oesophageal adenocarcinoma who received neoadjuvant chemotherapy and surgery from 2004 to 2012 was identified in the Northern Ireland Cancer Centre. Tissue microarrays were created in the Northern Ireland Biobank, with triplicate cores being sampled from each tumour. Immunohistochemical PTGS2 expression was scored by two independent assessors, with intensity and proportion of tumour staining being used to calculate H-scores for each patient. Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cancer-specific survival, and recurrence-free survival by PTGS2 expression, with adjustment for potential confounders. Patients were followed up for a mean of 3.0 years (standard deviation 1.8 years). The PTGS2 expression cut-off value was determined from the median H-score of the cohort (270/300). High (n = 79), as compared with low (n = 56), PTGS2 expression was associated with improved cancer-specific survival (adjusted HR 0.56, 95% CI 0.33-0.94; P = 0.03). PTGS2 expression was not significantly associated with recurrence-free survival (adjusted HR 0.85, 95% CI 0.52-1.38; P = 0.51).

CONCLUSIONS

High PTGS2 expression in oesophageal adenocarcinoma tissue was associated with improved overall and cancer-specific survival, in contrast to previous evidence. As this is the first study of its kind to include patients who had undergone neoadjuvant chemotherapy, further studies are needed to clarify these associations.

Practical guide for the comparison of two next-generation sequencing systems for solid tumour analysis in a universal healthcare system

AIMS

Although there have been excellent reports in the literature of validating next-generation sequencing, comparisons between two systems are not often published due to cost and time. We set out to establish that targetable mutations could be reliably detected with different gene panels and different chemistries using a common bioinformatics pipeline for meaningful comparisons to be made.

METHODS

After running selected formalin-fixed, paraffin-embedded samples through QPCR, Sanger sequencing and the 50 gene hotspot v2 panel from Life Technologies to determine standard-of-care variants, we compared the Oncomine panel from Life Technologies performed on a Personal Genome Machine (PGM) and the eight-gene actionable panel from Qiagen performed on a MiSeq platform. We used a common bioinformatics program following the creation of respective VCF files.

RESULTS

Both panels were accurate to above 90%, the actionable panel workflow was easier to perform but the lowest effective starting DNA load was obtained on the Oncomine workflow at 4 ng. Such minimal DNA can help with samples where there is limited material such as those for lung cancer molecular studies. We also discuss gene panel content and propose that increasing the gene profile of a panel will not benefit clinical laboratories where standard-of-care testing is all that is required.

CONCLUSIONS

Once recognised, it may be cost-effective for such laboratories to begin validation with an appropriate bioinformatics pipeline for targeted multigene hotspot molecular testing.

Critical Appraisal of Programmed Death Ligand 1 Reflex Diagnostic Testing: Current Standards and Future Opportunities

INTRODUCTION

Patient suitability to anti-programmed death ligand 1 (PD-L1) immune checkpoint inhibition is key to the treatment of NSCLC. We present, applied to PD-L1 testing: a comprehensive cross-validation of two immunohistochemistry (IHC) clones; our descriptive experience in diagnostic reflex testing; the concordance of IHC to in situ RNA (RNA-ISH); and application of digital pathology.

METHODS

Eight hundred thirteen NSCLC tumor samples collected from 564 diagnostic samples were analyzed prospectively, and 249 diagnostic samples analyzed retrospectively in tissue microarray format. Validated methods for IHC and RNA-ISH were tested in tissue microarrays and full sections and the QuPath system were used for digital pathology analysis.

RESULTS

Antibody concordance of clones SP263 and 22C3 validation was 97% to 98% in squamous cell carcinoma and adenocarcinomas, respectively. Clinical NSCLC cases were reported as PD-L1-negative (48%), 1% to 49% (23%), and more than 50% (29%), with differences associated to tissue-type and EGFR status. Comparison of IHC and RNA-ISH was highly concordant in both subgroups. Comparison of digital assessment versus manual assessment was highly concordant. Discrepancies were mostly around the 1% clinical threshold. Challenging IHC interpretation included 1) calculating the total tumor cell denominator and the nature of PD-L1 expressing cell aggregates in cytology samples; 2) peritumoral expression of positive immune cells; 3) calculation of positive tumor percentages around clinical thresholds; and 4) relevance of the 100 malignant cell rule.

CONCLUSIONS

Sample type and EGFR status dictate differences in the expected percentage of PD-L1 expression. Analysis of PD-L1 is challenging, and interpretative guidelines are discussed. PD-L1 evaluations by RNA-ISH and digital pathology appear reliable, particularly in adenocarcinomas.

Automated Tumour Recognition and Digital Pathology Scoring Unravels New Role for PD-L1 in Predicting Good Outcome in ER-/HER2+ Breast Cancer

The role of PD-L1 as a prognostic and predictive biomarker is an area of great interest. However, there is a lack of consensus on how to deliver PD-L1 as a clinical biomarker. At the heart of this conundrum is the subjective scoring of PD-L1 IHC in most studies to date. Current standard scoring systems involve separation of epithelial and inflammatory cells and find clinical significance in different percentages of expression, e.g., above or below 1%. Clearly, an objective, reproducible and accurate approach to PD-L1 scoring would bring a degree of necessary consistency to this landscape. Using a systematic comparison of technologies and the application of QuPath, a digital pathology platform, we show that high PD-L1 expression is associated with improved clinical outcome in Triple Negative breast cancer in the context of standard of care (SoC) chemotherapy, consistent with previous findings. In addition, we demonstrate for the first time that high PD-L1 expression is also associated with better outcome in ER- disease as a whole including HER2+ breast cancer. We demonstrate the influence of antibody choice on quantification and clinical impact with the Ventana antibody (SP142) providing the most robust assay in our hands. Through sampling different regions of the tumour, we show that tumour rich regions display the greatest range of PD-L1 expression and this has the most clinical significance compared to stroma and lymphoid rich areas. Furthermore, we observe that both inflammatory and epithelial PD-L1 expression are associated with improved survival in the context of chemotherapy. Moreover, as seen with PD-L1 inhibitor studies, a low threshold of PD-L1 expression stratifies patient outcome. This emphasises the importance of using digital pathology and precise biomarker quantitation to achieve accurate and reproducible scores that can discriminate low PD-L1 expression.

Sex hormone receptor expression and survival in esophageal adenocarcinoma: a prospective cohort study

INTRODUCTION

A striking epidemiological feature of esophageal adenocarcinoma (EAC) is its strong, unexplained male predominance but few studies have evaluated the prevalence of sex hormone receptor expression in EAC.

RESULTS

A low proportion of EAC tumors stained positive for ERα (4%) and AR (3%) while approximately one third stained positive for ERβ (31%). After a mean follow-up of 3 years (max 9 years), no significant associations were seen for ERα, ERβ or AR expression and EAC recurrence or survival. A non-significant reduction in mortality was observed for positive ERβ tumor expression, when restricting to patients with gastro-esophageal junctional (GEJ) cancer (HR 0.58, 95% CI 0.33, 1.03, p = 0.06).

MATERIALS AND METHODS

We identified all EAC patients who underwent neo-adjuvant chemotherapy prior to surgical resection between 2004-2012 in the Northern Ireland Cancer Centre. Immunohistochemical expression of ERα, ERβ and AR was scored on triplicate cores to generate H-scores. Cox proportional hazards regression was used to evaluate the association between sex hormone receptor expression and overall, cancer-specific and recurrence-free survival.

CONCLUSION

We found little evidence of ERα or AR expression in EAC. A moderate proportion expressed ERβ and there was suggestive evidence that its expression was associated with improved survival in GEJ cancer patients.

Use of Plasma with High Levels of lonised Calcium in the Production of Model Scale Goagulation Factor Concentrates

We have attempted to exploit the Ca2+ -dependent stability of factor VIII in producing factor VIII concentrates of higher yield. Plasma levels of ionised calcium were increased in two ways: (a) whole blood collection into half-strength citrate CPD anticoagulant, leading to free Ca2+ levels of ca 120 µM and (b) apheresis collection of plasma which was then recalcified to free Ca2+ levels of ca 300 µM under heparin cover. Coagulation factor concentrates were prepared using model versions of our industrial scale manufacturing methods. Factor VIII yield was increased through low citrate collection. This did not compromise factor IX yield or thrombogenic potential. Use of recalcified heparinised plasma did not lead to any improvement in factor VIII yield and resulted in a marked drop in factor IX recovery, possibly from interference by heparin of factor IX binding in ion-exchange chromatography. The benefits accruable through the use of half-strength citrate CPD anticoagulant support the continued evaluation of this preservative in large scale blood collection and fractionation. The deleterious effects of heparin in charge-mediated plasma fractionations may pose serious difficulties in harvesting vitamin K dependent factors.

Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.

Management of hyperglycaemia and steroid (glucocorticoid) therapy: a guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care group

Glucocorticoids (steroids) are widely used across many medical specialities for their anti-inflammatory and immunosuppressive properties. However, one of their major side effects is the development of hyperglycaemia. It is well recognized that high glucose levels in people with diabetes in hospital are associated with harm and increased lengths of hospital stay. The use of glucocorticoid (steroid) treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control, and this may be termed 'steroid-induced hyperglycaemia', and will warrant temporary additional, and more active, glycaemic management. A rise in glucose may occur in people without a known diagnosis of diabetes, and this may be termed 'steroid-induced diabetes'. There is a lack of evidence to guide how people with hyperglycaemia should be managed, and much of the guidance given here is a consensus based on best practice collated from around the United Kingdom. Where evidence is available, this is referenced. These guidelines on the management of people with diabetes treated with steroids has been adapted specifically for Diabetic Medicine. The full version of the guidelines can be found on line at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group.

Abstract 4049: Assessment of immune biomarkers by digital pathological analysis across a large colorectal cancer patient cohort predicts patient outcome and may provide a clinically relevant therapeutic index for immunotherapeutic treatment stratification

Introduction: Colorectal cancer (CRC) is a heterogeneous malignancy, treatment for which has principally been cytotoxic chemotherapy. Herein we describe the assessment of immune-biomarkers in a large patient cohort, demonstrating the therapeutic potential of immunotherapy in CRC. Methods: By immunohistochemistry, employing REMARK criteria, using well-validated antibodies, 4 biomarkers (CD3, CD4, CD8, FOXP3) in over 1000 cases, represented across 33 TMAs, were assessed for their protein expression. Digital pathological assessment of immune biomarker densities were quantified via the application of QuPath, an open source digital pathology platform, developed at Queens University, Belfast (https://qupath.github.io.). Biomarker densities were dichotomised by R.O.C analysis. Kaplan-Meier curves (Log-rank p values) were used to assess the impact of immune cell densities on overall survival (OS) and progression-free survival (PFS). Hazard ratios were assessed using the Cox proportional hazards regression model for univariate analysis. Spearman's rank was used to assess correlations of the biomarkers. Results: Expression of two biomarkers were found to vary by stage and three significantly affected OS. Across the patient cohort CD3, CD4 and CD8 were individually shown to be positively prognostic for OS alone (log-rank p = 0.0007, p = 8.65e-06, p = 0.006, respectively). CD4 demonstrated a more significant impact on OS in later stage disease (Log-rank stage II p = 0.0017, stage III p = 0.0002), while conversely CD8 only showed significance in earlier stage disease (Log-rank stage II p = 0.009, stage III p = 0.546). Although significantly associated with OS and within all stages, CD3 showed no differential expression in a particular stage. Correlative analysis demonstrated a statistically significant association between biomarkers. Upon univariate analysis, all biomarkers remained significantly prognostic for OS. All analyses were performed using R. Conclusions: These data demonstrate the prognostic significance of adaptive immune markers in a large CRC cohort on OS. Moreover, stage specific expression maybe clinically relevant and assessment within stages II and III may provide important stratifications for specific immunotherapy treatment regimes. We additionally add weight to the beneficial utility of digital pathology and its potential for integration into routine tissue biomarker assessment. Additional analysis of immune checkpoint and adaptive immune biomarkers in CRC is warranted.

Citation Format: Matthew P. Humphries, Stephanie Craig, Victoria Bingham, Maurice Loughrey, Helen Coleman, Liam Murray, Maughan Tim, Stephen McQuaid, Jacqueline James, Manuel Salto-Tellez. Assessment of immune biomarkers by digital pathological analysis across a large colorectal cancer patient cohort predicts patient outcome and may provide a clinically relevant therapeutic index for immunotherapeutic treatment stratification [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4049.