Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

NCCN Guidelines® Insights: Hematopoietic Cell Transplantation, Version 3.2022

The NCCN Guidelines for Hematopoietic Cell Transplantation (HCT) provide an evidence- and consensus-based approach for the use of autologous and allogeneic HCT in the management of malignant diseases in adult patients. HCT is a potentially curative treatment option for patients with certain types of malignancies; however, recurrent malignancy and transplant-related complications often limit the long-term survival of HCT recipients. The purpose of these guidelines is to provide guidance regarding aspects of HCT, including pretransplant recipient evaluation, hematopoietic cell mobilization, and treatment of graft-versus-host disease-a major complication of allogeneic HCT-to enable the patient and clinician to assess management options in the context of an individual patient's condition. These NCCN Guidelines Insights provide a summary of the important recent updates to the NCCN Guidelines for HCT, including the incorporation of a newly developed section on the Principles of Conditioning for HCT.

A systematic review and meta-analysis of randomized controlled trials comparing arthrocentesis with conservative management for painful temporomandibular joint disorder

The aim of this study was to determine whether arthrocentesis is superior to conservative treatment in the management of painful temporomandibular joint disorders with restricted opening. A systematic review was undertaken of prospective randomized controlled trials (RCT) comparing arthrocentesis to conservative management, identified in the MEDLINE and PubMed databases. Inclusion criteria included a 6-month follow-up, with clinical assessment of the patients and painful restricted mouth opening. Data extracted included pain measured on a visual analogue scale and maximum mouth opening measured in millimetres. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2 for RCTs, and a meta-analysis with the random-effects model was undertaken. Of 879 records retrieved, seven met the inclusion criteria; these RCTs reported the results at 6 months for 448 patients. One study had a low risk of bias, four studies had an uncertain risk, and two had a high risk of bias. In the meta-analysis, arthrocentesis was statistically superior to conservative management at 6 months for an increase in maximum mouth opening (1.12 mm, 95% confidence interval 0.45-1.78 mm; P = 0.001; I² = 87%) and borderline superior for pain reduction (-1.09 cm, 95% confidence interval -2.19 to 0.01 cm; P = 0.05; I² = 100%). However, these differences are unlikely to be clinically relevant.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

COVID-19 Pneumonia: Clinical Manifestations

Coronavirus disease-2019 (COVID-19) pneumonia has diverse clinical manifestations, which have shifted throughout the pandemic. Formal classifications include presymptomatic infection and mild, moderate, severe, and critical illness. Social risk factors are numerous, with Black, Hispanic, and Native American populations in the United States having suffered disproportionately. Biological risk factors such as age, sex, underlying comorbid burden, and certain laboratory metrics can assist the clinician in triage and management. Guidelines for classifying radiographic findings have been proposed and may assist in prognosis. In this article, we review the risk factors, clinical course, complications, and imaging findings of COVID-19 pneumonia.

Macrophage Lysosomal Alkalinization Drives Invasive Aspergillosis in a Mouse Cystic Fibrosis Model of Airway Transplantation

Cystic fibrosis (CF) lung transplant recipients (LTRs) exhibit a disproportionately high rate of life-threatening invasive aspergillosis (IA). Loss of the cystic fibrosis transmembrane conductance regulator (CFTR-/-) in macrophages (mφs) has been associated with lyosomal alkalinization. We hypothesize that this alkalinization would persist in the iron-laden post-transplant microenvironment increasing the risk of IA. To investigate our hypothesis, we developed a murine CF orthotopic tracheal transplant (OTT) model. Iron levels were detected by immunofluorescence staining and colorimetric assays. Aspergillus fumigatus (Af) invasion was evaluated by Grocott methenamine silver staining. Phagocytosis and killing of Af conidia were examined by flow cytometry and confocal microscopy. pH and lysosomal acidification were measured by LysoSensorTM and LysotrackerTM, respectively. Af was more invasive in the CF airway transplant recipient compared to the WT recipient (p < 0.05). CFTR-/- mφs were alkaline at baseline, a characteristic that was increased with iron-overload. These CFTR-/- mφs were unable to phagocytose and kill Af conidia (p < 0.001). Poly(lactic-co-glycolic acid) (PLGA) nanoparticles acidified lysosomes, restoring the CFTR-/- mφs’ ability to clear conidia. Our results suggest that CFTR-/- mφs’ alkalinization interacts with the iron-loaded transplant microenvironment, decreasing the CF-mφs’ ability to kill Af conidia, which may explain the increased risk of IA. Therapeutic pH modulation after transplantation could decrease the risk of IA.

Using Donor-Derived Cell-Free DNA for Assessment of Myocardial Injury in Heart Transplant Recipients After SARS-CoV2 Infection

Purpose

A link between SARS-CoV2 infection and myocardial injury has been described. Our center utilizes non-invasive surveillance with gene expression profiling and donor-derived cell-free DNA (dd-cfDNA) in heart transplant (HTx) patients who are either stable or in whom invasive surveillance is contraindicated. We evaluated whether HTx recipients diagnosed with SARS-CoV2 infection demonstrated evidence of myocardial allograft injury using dd-cfDNA.

Methods

HTx recipients were included if they had dd-cfDNA testing (AlloSure; CareDx Inc., Brisbane, CA) within 60 days of their initial SARS-CoV2 diagnosis. Data on hospitalization, therapy, and clinical outcomes was captured. Dd-cfDNA results at the assay limit of detection (LOD, <0.12%) were set equal to the LOD.

Results

Between 3/2020 and 6/2021, we identified 12 HTx recipients with SARS-CoV2 and dd-cfDNA results within the specified time period; median age was 55 (IQR 28 - 64.5) with infection occurring 506.5 days (IQR 176 - 803.5) after transplant. Mean dd-cfDNA was 0.13 ± 0.03%, assessed 26 (IQR 20 - 35) days after infection. Prior results, available for 9 patients and obtained a median of 33 (IQR 27 - 59) days prior to infection, did not differ from post-infection values (0.13 ± 0.02%, p = 0.66). Following diagnosis, 8 (67%) patients were hospitalized; 5 had mycophenolate held, 2 received steroids, 2 received convalescent plasma, 4 received remdesivir, and 1 received monoclonal Ab therapy. At a median follow-up time of 304 (IQR 212.5 - 331) days after diagnosis, all twelve patients were alive with good allograft function (mean ejection fraction 59 ± 4.8%); interval clinically-relevant immunologic outcomes included one episode of rejection (pAMR1) and three (25%) findings of de novo donor-specific antibodies (dnDSA).

Conclusion

In this single-center pilot study assessing myocardial injury among HTx recipients within 2 months of SARS-CoV2 infection, the majority of patients had low dd-cfDNA results (<0.15%) and demonstrated good intermediate-term (6-12 months) graft function. While limited by sample size and protocol-based inclusion criteria, our findings suggest that sustained myocardial injury in HTx recipients after SARS-CoV2 infection may not be common. The impact of SARS-CoV2 infection on immunologic outcomes including rejection and dnDSA in this population merit further study.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Hematopoietic Cell Transplantation, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Hematopoietic cell transplantation (HCT) involves the infusion of hematopoietic progenitor cells into patients with hematologic disorders with the goal of re-establishing normal hematopoietic and immune function. HCT is classified as autologous or allogeneic based on the origin of hematopoietic cells. Autologous HCT uses the patient's own cells while allogeneic HCT uses hematopoietic cells from a human leukocyte antigen-compatible donor. Allogeneic HCT is a potentially curative treatment option for patients with certain types of hematologic malignancies, and autologous HCT is primarily used to support patients undergoing high-dose chemotherapy. Advances in HCT methods and supportive care in recent decades have led to improved survival after HCT; however, disease relapse and posttransplant complications still commonly occur in both autologous and allogeneic HCT recipients. Allogeneic HCT recipients may also develop acute and/or chronic graft-versus-host disease (GVHD), which results in immune-mediated cellular injury of several organs. The NCCN Guidelines for Hematopoietic Cell Transplantation focus on recommendations for pretransplant recipient evaluation and the management of GVHD in adult patients with malignant disease.

Characterization of atrial lesion safety and efficacy utilizing a circular catheter and the IRE generator with an in vivo porcine model

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Biosense Webster, Inc.

Introduction/Objectives:

Pulsed field ablation (PFA) is a non-thermal ablative method that delivers high voltage, very-short duration pulses that cause pore formation in the cytoplasmic membrane and cell death. The tissue selectivity of PFA is expected to reduce the risk of collateral tissue injury compared to radiofrequency catheter ablation (RFCA), while maintaining effectiveness.  The objective of this study was to perform pulmonary vein (PV) isolation in a porcine model to characterize the safety and performance of a novel, fully-integrated biphasic PFA system. The system is comprised of a multi-channel generator, a variable loop circular catheter, and an integrated irreversible electroporation (IRE) mapping software module.

Methods

The study evaluated safety and efficacy of IRE in 8 healthy swine. First, to evaluate safety, multiple ablations were performed at various cardiac structures, including within the lumen of the right pulmonary vein (RIPV), at the right superior pulmonary vein (RSPV) ostium, and adjacent to the esophagus. Second, to evaluate efficacy, animals were recovered and followed for 30 (±3) days, then re-mapped. Gross pathological and histopathological examinations were performed to assess for procedural injury, chronic thrombosis, tissue ablation, depth of penetration, healing, and level of inflammatory response.

Results

All 8 swine survived for the 30 (±3) day follow up (FU) period. There were no acute (day of procedure) incidents of pulmonary vein narrowing of &gt;70%, nor at 30 d follow-up (FU), even when ablation was purposefully performed directly deep to the ostium of the vein. No injury was seen grossly or histologically in the adjacent esophagus. All PVs were durably isolated as confirmed by bidirectional block at the 30 (±3) day re-map procedure, and histological examination showed complete, transmural necrosis around the entire circumference of the ablated section of the right PVs [Figure].

Conclusion(s): This pre-clinical evaluation of a fully integrated PFA system demonstrated effective and durable ablation of cardiac tissue and PV isolation with no collateral damage to adjacent structures. Notably, histological staining confirmed complete transmural cell necrosis around the circumference of the ostial PV at 30 days. Abstract Figure. PVI maps (A) histology (B) and safety(C)

The Use of Factor Eight Inhibitor Bypass Activity (FEIBA) for the Treatment of Perioperative Hemorrhage in Left Ventricular Assist Device Implantation

OBJECTIVE

To test the hypothesis that factor eight inhibitor bypassing activity (FEIBA) can be used to control bleeding following left ventricular assist device (LVAD) implantation without increasing the 14-day composite thrombotic outcome of pump thrombus, ischemic cerebrovascular accidents, pulmonary embolism, and deep venous thrombosis.

DESIGN

Retrospective cohort study.

SETTING

Academic hospital.

PARTICIPANTS

Three hundred nineteen consecutive patients who underwent LVAD implantation (December 1, 2009 to December 30, 2018).

INTERVENTION

FEIBA administered to control perioperative hemorrhage.

MEASUREMENTS AND MAIN RESULTS

The 82 patients (25.7%) in the FEIBA cohort had more risk factors for perioperative hemorrhage, such as lower preoperative platelet count (169 ± 66 v 194 ± 68 × 10³/mL, p = 0.004), prior cardiac surgery (36.6% v 21.9%, p = 0.008), and longer cardiopulmonary bypass (CPB) time (100.3 v 75.2 minutes, p = 0.001) than the 237 controls. After 16.6 units (95% CI: 14.3-18.9) of blood products were given, 992 units (95% CI: 821-1163) of FEIBA were required to control bleeding in the FEIBA cohort. Compared to the controls, there were no differences in the 14-day composite thrombotic outcome (11.0% v 7.6%, p = 0.343) or mortality rate (3.7% v 1.3%, p = 0.179). Multivariate logistical regression identified preoperative international normalized ratio (odds ratio [OR]: 1.30, 95% CI: 1.04-1.62) and CPB time (OR: 1.11, 95% CI: 1.02-1.20) as risk factors for 14-day thrombotic events, but FEIBA usage was not associated with an increased risk.

CONCLUSIONS

In this retrospective cohort study, the use of FEIBA (∼1,000 units, ∼13 units/kg) to control perioperative hemorrhage following LVAD implantation was not associated with increases in mortality or composite thrombotic outcome.

Efficacy and safety of lurasidone in adolescents and young adults with schizophrenia: Pooled analysis of double-blind, placebo-controlled 6-week studies

Introduction

Onset of schizophrenia commonly occurs during late adolescence or early adulthood and is often characterized by greater symptom severity and impairment.

Objectives

To evaluate the efficacy and safety of lurasidone in the treatment of acute schizophrenia in adolescents and young adults.

Methods

The 4 studies in this pooled analysis used similar study designs. Patients (ages 13-25 years) were randomized to 6 weeks of double-blind, placebo-controlled treatment with once-daily lurasidone (37 mg, 74 mg, 111 mg, 148 mg). The primary outcome was endpoint change in the Positive and Negative Syndrome Scale (PANSS) total score; secondary measures included the Clinical Global Impression, Severity scale (CGI-S).

Results

The safety population consisted of 537 patients; 79.1% completed the studies. Treatment with lurasidone was significant (P<0.001) at Week 6 endpoint for change in the PANSS total score, with higher effect sizes (ES) at higher doses (37 mg, 0.53; 74 mg, 0.57; 111 mg, 0.67; 148 mg, 1.35); significance was also observed for change in the CGI-S (37 mg, 0.51; 74 mg, 0.49; 111 mg, 0.57; 148 mg, 1.75). For lurasidone (combined doses), 3 adverse events occurred with a frequency ≥5% (nausea, 13.5%; somnolence, 12.1%; akathisia, 10.1%); 4.8% of patients discontinued due to an adverse event. At LOCF-endpoint, 3.6% of patients had weight gain ≥7%, and 1.5% had weight loss ≥7%. Minimal median changes were observed at endpoint in metabolic lab values.

Conclusions

In adolescents and young adults with schizophrenia, treatment with lurasidone in doses of 37-148 mg/d was a safe, well-tolerated, and effective treatment.

Disclosure

Presenter is an employee of Sunovion Pharmaceuticals Inc. The study summarized in this Abstract was supported by Funding from Sunovion Pharmaceuticals Inc.

Comprehensive analysis utilizing flow cytometry and immunohistochemistry reveals inflammatory changes in local endometrial and systemic dendritic cell populations in endometriosis

STUDY QUESTION

What are the detailed endometrial tissue specific and systemic dendritic cell (DC) subset disturbances in endometriosis?

SUMMARY ANSWER

This study confirms myeloid DC (mDC) and plasmacytoid DC subsets are readily identified in endometrial tissue and shows both endometrial and circulating differences in DC populations in women with endometriosis, with disease stage-specific relationships evident locally in the endometrium.

WHAT IS KNOWN ALREADY

Immune factors in the uterus, the peritoneal environment and systemically are implicated in the pathogenesis and progression of both endometriosis and infertility. While there is some evidence that endometrial DC populations are altered in endometriosis, DC subset involvement in both the endometrium and peripheral blood have not been comprehensively investigated so the functional consequences have been unknown.

STUDY DESIGN, SIZE, DURATION

This prospective cross-sectional cohort study compares circulating and endometrial DC populations in women of reproductive age with and without endometriosis (n = 55 and 30, respectively), wherein each participant donated samples at a single time point. Study participants were surveyed for menstrual cycle phase, American Society for Reproductive Medicine (ASRM) endometriosis disease stage and fertility status (where possible).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Peripheral blood samples were processed into mononuclear cells for analysis by flow cytometry, and endometrial samples were analysed by immunohistochemistry and dissociated into single-cell suspension for flow cytometry.

MAIN RESULTS AND THE ROLE OF CHANCE

In the endometrium of women with endometriosis, IRF-8+ cells were increased during the proliferative phase (P = 0.014), total DC proportions increased in the secretory phase (P = 0.038) and normal menstrual cyclical fluctuations in CD1c+ and IRF-8+ cells blunted; indicative of a consistently inflammatory tissue environment. The inflammatory changes in CD141+ and IRF-8+ populations in the endometrium of women with endometriosis were particularly evident in more advanced ASRM stages of the disease (respective P-values 0.032 and 0.045). There was also evidence of systemic inflammation in women with endometriosis, with increased circulating CD141+ mDC proportions (overall P = 0.040, secretory phase P = 0.021).

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

As is common in this type of study, one of the main limitations was small sample numbers, particularly during the menstrual phase of the cycle.

WIDER IMPLICATIONS OF THE FINDINGS

Further phenotyping of local and circulating immune cell subtypes is critical to improving understanding of endometriosis pathogenesis and immune contributions to infertility associated with the disease.

STUDY FUNDING/COMPETING INTEREST(S)

This research was financially supported by a Sydney Medical School and Balnaves Foundation Kick Start Grant and the Department of Obstetrics, Gynaecology and Neonatology at The University of Sydney. The authors have no conflicts of interest to declare.

Stability and performance of the EnSite Precision cardiac mapping system for electrophysiology mapping and ablation procedures: results from the EnSite Precision observational study

Background

The EnSite Precision™ Cardiac Mapping System is a catheter navigation and mapping system capable of displaying the three-dimensional (3D) position of conventional and sensor enabled electrophysiology catheters, as well as displaying cardiac electrical activity as waveform traces and dynamic 3-D maps of cardiac chambers.

Objective

The EnSite Precision™ Observational Study was designed to quantify and characterize the use of the EnSite Precision™ Cardiac Mapping System for mapping and ablation of cardiac arrhythmias in a real-world environment and to evaluate procedural and subsequent clinical outcomes.

Methods

1065 patients were enrolled at 38 centers in the U.S. and Canada between 2017–2018. Eligible subjects were adults undergoing a cardiac electrophysiology mapping and radiofrequency ablation procedures using the EnSite Precision™ System.

Results

Of 989 patients who completed the protocol, a geometry was created in 936 (94.7%). Most initial maps were created using Automap (n=545, 67.0%) or a combination of Automap and manually mapping (n=151, 18.6%). Median time to create an initial map was 9.0 min (IQR 5.0–15.0), with a median number of used mapping points per minute of 92.7 (IQR 30.0–192.0). During ablation, AutoMark was used in 817 (82.6%) of procedures. The most frequent metrics for lesion color were Impedance Drop or Impedance Drop Percent (45.5% combined), time (23.9%) and average force (14.2%). At Canadian sites where LSI was an option, it was used as the color metric in 87 (45.8%) of cases (10.6% overall). The EnSite System was stable throughout 79.7% (n=788 of 989) of procedures. Factors affecting stability were respiratory change (n=88 of 989, 8.9%), patient movement (n=73, 7.4%), CS Positional Reference dislodgement (n=32, 3.2%), and cardioversion (n=19, 1.9%). Conscious sedation was used in 189 (19.1%) of patients. Acute success was reached based on the pre-defined endpoints for the procedure in 97.4% (n=963) of cases.

Conclusion

In a real-world study analysis, the EnSite Precision™ mapping system was associated with a high prevalence of acute procedural success, low mapping times, and high system stability.

Funding Acknowledgement

Type of funding source: None

Abstract OT2-01-01: SANDPIPER: Phase III study of the PI3-kinase inhibitor taselisib (GDC-0032) plus fulvestrant in patients with estrogen receptor-positive, HER2-negative locally advanced or metastatic breast cancer enriched for patients with PIK3CA-mutant tumors

Background: PIK3CA mutations frequently occur in breast cancer (BC), being present in ∼40% of estrogen receptor (ER)-positive, HER2-negative breast tumors. PIK3CA mutations promote growth and proliferation of tumors and mediate resistance to endocrine therapies in BC. Taselisib is a potent and selective PI3-kinase (PI3K) inhibitor that displays greater selectivity for mutant PI3Kα than wild-type PI3Kα through a unique mechanism. In cell studies, taselisib preferentially degraded mutant compared with wild-type PI3Kα, which was not seen with alpelisib and pictilisib. Taselisib has enhanced activity against PIK3CA-mutant BC cell lines, and clinical data include confirmed partial responses in patients with PIK3CA-mutant BC treated with taselisib either as a single agent or in combination with fulvestrant.

Trial design: SANDPIPER is a double-blinded, placebo-controlled, randomized, phase III study, designed to evaluate efficacy and safety of taselisib plus fulvestrant in patients with ER-positive, HER2-negative locally advanced or metastatic BC. Patients will be randomized 2:1 to receive either taselisib (4 mg daily) or placebo plus fulvestrant (500 mg intramuscular on Days 1 and 15 of Cycle 1, and on Day 1 of each subsequent 28-day cycle). Randomization will be stratified by visceral disease, endocrine sensitivity, and geographic region. The study enriches for patients with PIK3CA-mutant tumors who will be randomized separately from those with non-mutant tumors.

Eligibility: Postmenopausal women with ER-positive, HER2-negative, locally advanced or metastatic BC are eligible if they have disease recurrence or progression during or after aromatase inhibitor treatment. A valid cobas® PIK3CA Mutation Test result via central assessment is required prior to enrollment.

Aims: The primary efficacy endpoint is investigator-assessed progression-free survival (PFS) in patients with PIK3CA-mutant tumors. Additional endpoints include overall survival (OS), objective response rate (ORR), clinical benefit rate (CBR), duration of objective response, safety, pharmacokinetics, and patient-reported outcomes.

Statistical methods: The primary efficacy analysis population will include all randomized patients with PIK3CA-mutant tumors. Patients will be grouped according to randomized treatment arm. Median PFS and OS will be estimated using Kaplan–Meier methodology. Cox proportional-hazards models, stratified by the stratification factors, will be used to estimate the hazard ratio with 95% confidence intervals (CIs). ORR, CBR, and their 95% CIs will be estimated. Duration of objective response will be estimated using Kaplan–Meier methodology. Quality of life will be analyzed and summarized. Safety will be analyzed for all treated patients according to actual treatment received.

Accrual: Target enrollment is 600 patients. The study is open for enrollment and, as at April 2016, over 200 patients have been enrolled. Clinicaltrials.gov ID: NCT02340221.

Contact information: For more information or to refer a patient, email global.rochegenentechtrials@roche.com or call 1-888-662-6728 (USA only).

Citation Format: Baselga J, Cortés J, De Laurentiis M, Dent S, Diéras V, Harbeck N, Hsu J, Jin H, Schimmoller F, Wilson TR, Im Y-H, Jacot W, Krop IE, Verma S. SANDPIPER: Phase III study of the PI3-kinase inhibitor taselisib (GDC-0032) plus fulvestrant in patients with estrogen receptor-positive, HER2-negative locally advanced or metastatic breast cancer enriched for patients with PIK3CA-mutant tumors [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 OT2-01-01.