International variations in serum PTH and calcium levels and their mortality associations in peritoneal dialysis patients: Results from PDOPPS

BACKGROUND

Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients.

METHODS

We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calciumAlb) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase.

RESULTS

Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calciumAlb were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calciumAlb ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calciumAlb 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries.

CONCLUSIONS

A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes.

LAY SUMMARY

Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.

Reducing hand radiation during renal access for percutaneous nephrolithotomy: a comparison of radiation reduction techniques

Percutaneous nephrolithotomy confers the highest radiation to the urologist's hands compared to other urologic procedures. This study compares radiation exposure to the surgeon's hand and patient's body when utilizing three different techniques for needle insertion during renal access. Simulated percutaneous renal access was performed using a cadaveric patient and separate cadaveric forearm representing the surgeon's hand. Three different needle-holding techniques were compared: conventional glove (control), a radiation-attenuating glove, and a novel needle holder. Five 300-s fluoroscopy trials were performed per treatment arm. The primary outcome was radiation dose (mSv) to the surgeon's hand. The secondary outcome was radiation dose to the patient. One-way ANOVA and Tukey's B post-hoc tests were performed with p < 0.05 considered significant. Compared to the control (3.92 mSv), both the radiation-attenuating glove (2.48 mSv) and the needle holder (1.37 mSv) reduced hand radiation exposure (p < 0.001). The needle holder reduced hand radiation compared to the radiation-attenuating glove (p < 0.001). The radiation-attenuating glove resulted in greater radiation produced by the C-arm compared to the needle holder (83.49 vs 69.22 mGy; p = 0.019). Patient radiation exposure was significantly higher with the radiation-attenuating glove compared to the needle holder (8.43 vs 7.03 mSv; p = 0.027). Though radiation-attenuating gloves decreased hand radiation dose by 37%, this came at the price of a 3% increase in patient exposure. In contrast, the needle holder reduced exposure to both the surgeon's hand by 65% and the patient by 14%. Thus, a well-designed low-density needle holder could optimize radiation safety for both surgeon and patient.

Automated Spot Counting in Microbiology

Biological samples are routinely analyzed for microbe concentration. The samples are diluted, loaded onto established host cell cultures, and incubated. If infectious agents are present in the samples, they form circular spots that do not contain the host cells. Each spot is assumed to be originated from a single microbial unit such as a bacterial colony forming unit or viral plaque forming unit. The undiluted sample concentration is estimated by counting the spots and back-calculating. Counting the number of spots by trained technicians is currently the gold standard but it is laborious, subjective, and hard to scale. This paper presents a new automated algorithm for spot counting, Localized and Sequential Thresholding (LoST). Validation studies showed that LoST performance was comparable with manual counting and outperformed several existing tools on images with overlapping spots. The LoST algorithm employs sequential thresholding through a two-stage segmentation and borrows information across all images from the same dilution series to fine-tune the count and identify right censoring. The algorithm increases the efficiency of the spot counting and the quality of the downstream analysis, especially when coupled with an appropriate statistical serial dilution model to enhance the undiluted sample concentration estimation procedure.

Nivolumab Plus Chemotherapy for Advanced Gastric, Gastroesophageal Junction, and Esophageal Adenocarcinoma: Analysis of Number Needed To Treat and Number Needed To Harm

PURPOSE

Nivolumab, a programmed cell death protein (PD)-1 inhibitor, was approved by the US Food and Drug Administration in 2021 advanced/metastatic gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma, in combination with fluoropyrimidine and platinum-based chemotherapy. In the present study, the number needed to treat (NNT) for overall survival (OS), progression-free survival (PFS), and objective response rate (ORR)-and the number needed to harm (NNH) for tolerability outcomes-with nivolumab + chemotherapy versus chemotherapy alone were determined.

METHODS

NNT and NNH were calculated as the reciprocal of the risk difference between the two treatment arms, with the 95% CIs calculated as the reciprocals of the upper and lower bounds of the 95% CI of the risk difference, using data from the CheckMate 649 study.

FINDINGS

Among all treated patients, the NNTs for OS over 1 and 2 years were 15.15 and 12.05; for PFS, 10.87 and 19.61; and for ORR over the entire trial period, 8.95. The corresponding NNTs in the subgroup with PD-L1 CPS ≥5 were less. The NNH for grade ≥3 treatment-related adverse events (TEAEs) over 1 year among all treated patients was 7.02.

IMPLICATIONS

The small estimated NNT values in this study suggest that patients would benefit from nivolumab + chemotherapy, and while the NNH for grade ≥3 TRAEs was small, the NNH for any individual TRAE were large or negative.

The association of low birthweight and prematurity on outcomes in children and adults with nephrotic syndrome-a NEPTUNE cohort study

BACKGROUND

In single-center studies, both preterm birth and low birth weight (LBW) are associated with worse outcomes in childhood nephrotic syndrome. Using the Nephrotic Syndrome Study Network (NEPTUNE) observational cohort, we tested the hypothesis that in patients with nephrotic syndrome, hypertension, proteinuria status, and disease progression would be more prevalent and more severe in subjects with LBW and prematurity singly or in combination (LBW/prematurity).

METHODS

Three hundred fifty-nine adults and children with focal segmental glomerulosclerosis (FSGS) or minimal change disease (MCD) and available birth history were included. Estimated glomerular filtration rate (eGFR) decline and remission status were primary outcomes, and secondary outcomes were kidney histopathology, kidney gene expression, and urinary biomarkers. Logistic regression was used to identify associations with LBW/prematurity and these outcomes.

RESULTS

We did not find an association between LBW/prematurity and remission of proteinuria. However, LBW/prematurity was associated with greater decline in eGFR. This decline in eGFR was partially explained by the association of LBW/prematurity with APOL1 high-risk alleles, but the association remained after adjustment. There were no differences in kidney histopathology or gene expression in the LBW/prematurity group compared to normal birth weight/term birth.

CONCLUSION

LBW and premature babies who develop nephrotic syndrome have a more rapid decline in kidney function. We did not identify clinical or laboratory features that distinguished the groups. Additional studies in larger groups are needed to fully ascertain the effects of (LBW) and prematurity alone or in combination on kidney function in the setting of nephrotic syndrome.

An Exploratory Study of Physical Therapists From High-Income Countries Practising Outside of Their Scope in Low and Middle-Income Countries

PURPOSE

To quantify how often physical therapists from high-income countries (HIC) travelling to low- and middle-income countries (LMIC) practise outside their scope of practice, in what circumstances, and their likelihood of doing the same in the future.

METHODS

An exploratory descriptive study using a survey.

RESULTS

One hundred and twenty-six licensed physical therapists from around the world participated. Physical therapists typically spent less than a month (73.8 per cent) in LMIC; 67.5 per cent believed that physical therapists practise outside of their scope, and 31.7 per cent reported doing so. Reasons were believing that something is better than nothing (47.5 per cent ), a mismatch between the physical therapist's and host's expectations (40.0 per cent ), and preserving their relationship with the host (25.0 per cent ). It was deemed appropriate by 64.5 per cent to practise outside of their scope in some situations and 53.8% considered repeating the activity in the future. Half of the respondent's first experience in LMIC occurred as a student or in their first decade of practice.

CONCLUSIONS

Working in LMIC requires a keen understanding of the risks and challenges associated with such experiences. To ensure best practice, a skill set that consists of critical self-reflection, systems thinking, and structural competency combined with clinical competency and accountability is imperative.

Quality-adjusted time without symptoms or toxicity analysis of nivolumab plus chemotherapy versus chemotherapy alone for the management of previously untreated patients with advanced gastric cancer, gastroesophageal junction cancer, or esophageal adenocarcinoma

BACKGROUND

The phase 3 CheckMate 649 established superior overall survival of nivolumab in combination with chemotherapy (NIVO + chemo) compared with chemotherapy (chemo) alone as a first-line treatment for patients with Her2-negative advanced gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma (GC/GEJC/EAC). This post hoc trial analysis aimed to evaluate the benefit of NIVO + chemo using quality-adjusted time without symptoms or toxicity (Q-TWiST) to further account for quality of life (QoL) in different health states depending on disease progression and treatment toxicity.

METHODS

Using data from CheckMate 649, we evaluated the quality-adjusted survival gain associated with NIVO + chemo compared with chemo alone among all randomized patients and repeated similar analyses among those with programmed cell death-ligand 1 (PD-L1) combined positive score (CPS) ≥ 5. Relative Q-TWiST gains of ≥ 10% were predefined as clinically important.

RESULTS

In all randomized patients, those receiving NIVO + chemo had a mean Q-TWiST gain of 1.8 (95% CI 0.9, 2.7) months compared with those receiving chemo alone. The relative Q-TWiST gain was estimated to be 12.8%. Patients with PD-L1 CPS ≥ 5 had greater quality-adjusted survival gain from NIVO + chemo with an estimated Q-TWiST gain of 2.8 (95% CI 1.5, 4.1) months, representing a relative gain of 20.6%. Subgroup analyses and sensitivity analyses with various QoL utility values yielded consistent findings in favor of NIVO + chemo compared with chemo alone. Q-TWiST gain from NIVO + chemo increased with longer duration of follow-up.

CONCLUSIONS

NIVO + chemo was associated with a statistically significant and clinically important gain in quality-adjusted survival compared with chemo alone among previously untreated patients with advanced GC/GEJC/EAC.

Better together? costs of first-line chemoimmunotherapy for advanced non-small cell lung cancer

OBJECTIVES

Recent advances have created options for first-line (1L) treatment of advanced/metastatic non-small cell lung cancer (aNSCLC). The study objectives were to describe the utilization of 3 classes of 1L treatment-chemotherapy (CT), immunotherapy (IO), and chemoimmunotherapy (IO+CT)-and the total, third-party payer, direct health care costs.

STUDY DESIGN

Retrospective, administrative claims database analysis of patients with aNSCLC who initiated 1L treatment between January 1, 2017, and May 31, 2019, with IO, CT, or IO+CT.

METHODS

Microcosting enumerated health care resource utilization, including antineoplastic drug costs, using standardized costs. Generalized linear models estimated per-patient per-month (PPPM) costs during 1L treatment, and adjusted cost differences in 1L among treatment cohorts were calculated using recycled predictions.

RESULTS

A total of 1317 IO-, 5315 CT-, and 1522 IO+CT-treated patients were identified. Utilization of CT declined from 72.3% to 47.6% between 2017 and 2019, replaced by use of IO+CT, which increased from 1.8% to 29.8%. Total PPPM costs in 1L were highest with IO+CT at $32,436, compared with $19,000 and $17,763 in the CT and IO cohorts, respectively. Adjusted analyses showed that PPPM costs were $13,933 (95% CI, $11,760-$16,105) higher in the IO+CT vs IO cohort (P < .001) and IO costs were $1024 (95% CI, $67-$1980) lower than CT (P = .04).

CONCLUSIONS

IO+CT accounts for almost one-third of 1L aNSCLC treatment modalities, coinciding with a reduction in treatment with CT. Costs for patients treated with IO were lower than those for patients treated with both IO+CT and CT alone, driven primarily by antineoplastic drug and associated medical costs.

SGLT2 inhibitors mitigate kidney tubular metabolic and mTORC1 perturbations in youth-onset type 2 diabetes

The molecular mechanisms of sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2i) remain incompletely understood. Single-cell RNA sequencing and morphometric data were collected from research kidney biopsies donated by young persons with type 2 diabetes (T2D), aged 12 to 21 years, and healthy controls (HCs). Participants with T2D were obese and had higher estimated glomerular filtration rates and mesangial and glomerular volumes than HCs. Ten T2D participants had been prescribed SGLT2i (T2Di[+]) and 6 not (T2Di[-]). Transcriptional profiles showed SGLT2 expression exclusively in the proximal tubular (PT) cluster with highest expression in T2Di(-) patients. However, transcriptional alterations with SGLT2i treatment were seen across nephron segments, particularly in the distal nephron. SGLT2i treatment was associated with suppression of transcripts in the glycolysis, gluconeogenesis, and tricarboxylic acid cycle pathways in PT, but had the opposite effect in thick ascending limb. Transcripts in the energy-sensitive mTORC1-signaling pathway returned toward HC levels in all tubular segments in T2Di(+), consistent with a diabetes mouse model treated with SGLT2i. Decreased levels of phosphorylated S6 protein in proximal and distal tubules in T2Di(+) patients confirmed changes in mTORC1 pathway activity. We propose that SGLT2i treatment benefits the kidneys by mitigating diabetes-induced metabolic perturbations via suppression of mTORC1 signaling in kidney tubules.

Patient-Reported Distress and Clinical Outcomes with Immuno-Oncology Agents in Metastatic Non-Small Cell Lung Cancer (mNSCLC): A Real-World Retrospective Cohort Study

OBJECTIVES

There are limited real-world data about patient-reported outcomes with immunotherapies (IO) in metastatic non-small cell lung cancer (mNSCLC). We describe patient-reported distress and clinical outcomes with IO-based treatments or cytotoxic chemotherapies (Chemo).

METHODS

We conducted a single-institution retrospective chart review of adults with mNSCLC treated at Duke from 03/2015 to 06/2020. At each visit, patients self-reported their distress level and sources of distress using the NCCN Distress Thermometer (DT) and its 39-item Problem List. We abstracted demographic, clinical, distress, and investigator assessed-clinical response data, then analyzed these using descriptive statistics and generalized estimating equations.

RESULTS

Data from 152 patients were analyzed in four groups: Chemo alone, IO + Chemo, single agent IO, dual agent IO. Distress was worse before treatment start in all groups, and the odds of actionable distress (DT score > 4) decreased by 10 % per month. The most frequent sources of distress were physical symptoms (e.g., fatigue, pain), which remained high longitudinally. Patients receiving IO had higher clinical response rates and a lower rate of unplanned healthcare encounters compared to patients treated with Chemo alone. Only one-third of all patients were seen by palliative care.

CONCLUSIONS

This single-center, real-world evidence study demonstrates that patients with mNSCLC experience significant distress prior to starting first-line treatment. IO treatment was associated with higher clinical benefit rates and lower healthcare utilization compared to chemotherapy. Symptom distress persists over time, highlighting potential unmet palliative and supportive care needs in mNSCLC care in the IO treatment era.

Serum Phosphorus Level Rises in US Hemodialysis Patients Over the Past Decade: A DOPPS Special Report

Mineral bone disorder (MBD) is a frequent consequence of chronic kidney disease, more so in patients with kidney failure treated by kidney replacement therapy. Despite the wide availability of interventions to control serum phosphate and parathyroid hormone levels, unmet gaps remain on optimal targets and best practices, leading to international practice pattern variations over time. In this Special Report, we describe international trends from the Dialysis Outcomes and Practice Patterns Study (DOPPS) for MBD biomarkers and treatments from 2002-2021, including data from a group of 7 European countries (Belgium, France, Germany, Italy, Spain, Sweden, United Kingdom), Japan, and the United States. From 2002-2012, mean phosphate levels declined in Japan (5.6 to 5.2 mg/dL), Europe (5.5 to 4.9 mg/dL), and the United States (5.7 to 5.0 mg/dL). Since then, levels rose in the United States (to mean 5.6 mg/dL, 2021), were stable in Japan (5.3 mg/dL), and declined in Europe (4.8 mg/dL). In 2021, 52% (United States), 27% (Europe), and 39% (Japan) had phosphate >5.5 mg/dL. In the United States, overall phosphate binder use was stable (80%-84% over 2015-2021), and parathyroid hormone levels rose only modestly. Although these results potentially stem from pervasive knowledge gaps in clinical practice, the noteworthy steady increase in serum phosphate in the United States over the past decades may be consequential to patient outcomes, an uncertainty that hopefully will soon be addressed by ongoing clinical trials. The DOPPS will continue to monitor international trends as new interventions and strategies ensue for MBD management in chronic kidney disease.

Quantification of Glomerular Structural Lesions: Associations With Clinical Outcomes and Transcriptomic Profiles in Nephrotic Syndrome

RATIONALE & OBJECTIVE

The current classification system for focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD) does not fully capture the complex structural changes in kidney biopsies nor the clinical and molecular heterogeneity of these diseases.

STUDY DESIGN

Prospective observational cohort study.

SETTING & PARTICIPANTS

221 MCD and FSGS patients enrolled in the Nephrotic Syndrome Study Network (NEPTUNE).

EXPOSURE

The NEPTUNE Digital Pathology Scoring System (NDPSS) was applied to generate scores for 37 glomerular descriptors.

OUTCOME

Time from biopsy to complete proteinuria remission, time from biopsy to kidney disease progression (40% estimated glomerular filtration rate [eGFR] decline or kidney failure), and eGFR over time.

ANALYTICAL APPROACH

Cluster analysis was used to group patients with similar morphologic characteristics. Glomerular descriptors and patient clusters were assessed for associations with outcomes using adjusted Cox models and linear mixed models. Messenger RNA from glomerular tissue was used to assess differentially expressed genes between clusters and identify genes associated with individual descriptors driving cluster membership.

RESULTS

Three clusters were identified: X (n = 56), Y (n = 68), and Z (n = 97). Clusters Y and Z had higher probabilities of proteinuria remission (HRs of 1.95 [95% CI, 0.99-3.85] and 3.29 [95% CI, 1.52-7.13], respectively), lower hazards of disease progression (HRs of 0.22 [95% CI, 0.08-0.57] and 0.11 [95% CI, 0.03-0.45], respectively), and lower loss of eGFR over time compared with X. Cluster X had 1,920 genes that were differentially expressed compared with Y+Z; these reflected activation of pathways of immune response and inflammation. Six descriptors driving the clusters individually correlated with clinical outcomes and gene expression.

LIMITATIONS

Low prevalence of some descriptors and biopsy at a single time point.

CONCLUSIONS

The NDPSS allows for categorization of FSGS/MCD patients into clinically and biologically relevant subgroups, and uncovers histologic parameters associated with clinical outcomes and molecular signatures not included in current classification systems.

636 Patient-reported distress with immunotherapy-based first-line treatment for mNSCLC: a real-world evidence study

Background

There are limited published real-world data about patient-reported outcomes with immunotherapies (IO) in metastatic non-small cell lung cancer (mNSCLC). We describe the patient experience with first-line IO-based treatments vs. chemotherapy in this setting.

Methods

We conducted a retrospective chart review of adult patients with mNSCLC treated at Duke University from March 2015-June 2020. At each visit, patients self-reported their distress level and sources of distress using the NCCN Distress Thermometer (DT) tool, consisting of an 11-point ordinal scale reporting overall distress and a 39-item Problem List (PL). We abstracted demographic, clinical, distress, response data (by investigator assessment), then analyzed these data using descriptive statistics and generalized estimating equations accounting for clustering of clinic visits within participants and generalized linear models accounting for study exposure time.

Results

152 patients were analyzed in four groups: single agent immunotherapy (IO alone, n=40), dual immunotherapy (IO+IO, n=27), chemo-immunotherapy (IO+Chemo, n=46), and chemotherapy alone (n=39). Patients were followed for up to 1 year or earliest of: death, last contact, or 2nd line therapy start. Participants' mean age was 65.7 years. In all patients, overall distress was worst before treatment start (figure 1), and the odds of actionable distress (DT score >4) decreased over time by 10% per month (OR=0.901, 95% CI:0.813, 0.998, p=0.045). There were no significant differences in actionable distress across treatment groups. Symptom distress remained high over time, while other sources of distress (practical, family, and emotional) decreased. The most frequent sources of symptom distress were fatigue (90% of patients ever reported, 40% of all DTs), pain (75% of patients, 30% of DTs), and breathing (68% of patients, 22% of DTs) (figure 2). Treatment with chemotherapy alone yielded the fewest tumor responses (50%) and lowest clinical benefit rate (74.4%) compared to any IO therapy. Unplanned healthcare utilization was significantly different across treatment groups; IO+IO resulted in the lowest utilization rate (0.57, 95% CI:0.36, 0.90), while chemotherapy yielded the highest (1.46, 95% CI:1.00,2.12). Palliative care was utilized in 40% of patients; among those with actionable distress at any time (n=113; 74%), 53% (n=60) had a palliative care visit.

Conclusions

This single-center, real-world evidence study demonstrates that patients with mNSCLC experience significant distress prior to starting first-line treatment, with persistent symptom distress over time. Furthermore, IO treatment is associated with reduced healthcare utilization compared to chemotherapy. Increased utilization of integrated palliative care services may improve the patient experience of mNSCLC treatment, especially for management of symptom distress.

Ethics Approval

This clinical study involves retrospective analyses of data extracted from medical charts and was approved by Duke University School of Medicine Institutional Review Board (IRB#106013).

Consent

As there was no prospective enrollment of subjects, consent was obtained through a Waiver or Alteration of Consent and Authorization and Decedent Research Notification of the Health Insurance Portability and Accountability Act (HIPAA) 1996.

Abstract 636 Figure 1

Overall distress thermometer scores over time

Abstract 636 Figure 2

Most frequently reported problems by treatment type

Treatment patterns in patients with metastatic non-small-cell lung cancer in the era of immunotherapy

Background: Chemotherapy (CT) alone was previously standard first-line (1L) therapy for metastatic non-small-cell lung cancer (NSCLC) but alternative treatments, including immunotherapy (I-O), are now available. Patients & methods: In this retrospective study, adults with stage IV NSCLC who initiated 1L treatment between 1 August 2018 and 31 December 2019 and had ≥2 visits were identified in the Flatiron database. Patients were followed up until 30 June 2020. Baseline characteristics and treatment patterns were described by treatment group: CT, I-O + CT, I-O monotherapy and other. Results: Approximately 20% of patients received 1L CT in the 2018-2019 timeframe studied; these patients tended to have squamous histology and low (≤49%) programmed death ligand-1 expression. Conclusion: A proportion of patients with metastatic NSCLC still receive 1L CT despite the availability and widespread use of I-O therapies.

Real-world outcomes of immunotherapy-based regimens in first-line advanced non-small cell lung cancer

BACKGROUND

First-line (1L) immunotherapy (I-O) has improved outcomes in patients with advanced non-small cell lung cancer (NSCLC) in clinical trials and is now routinely used alone or combined with chemotherapy. Although efficacy and safety of I-O therapies have been established in clinical trials, little is known about their performance and long-term efficacy in the real-world setting. We aimed to characterize real-world outcomes for patients with advanced NSCLC treated with 1L I-O therapy in the United States.

METHODS

Patients aged ≥18 years with confirmed advanced (stage III-IV) NSCLC who received either 1L I-O monotherapy or single-agent I-O combined with chemotherapy on or after January 1, 2016 were identified from the Flatiron Health database. Primary objectives were to examine overall survival (OS) and real-world progression-free survival. Index date was defined as date of 1L treatment initiation; data cut-off date was June 30, 2020.

RESULTS

Among 4271 patients receiving I-O plus chemotherapy, median OS was 10.6 (95 % confidence interval [CI], 9.3-11.8) months in patients with squamous NSCLC (n=814) and 12.0 (95 % CI, 11.3-12.8) months in those with non-squamous disease (n=3457). Regardless of histology, patients with high (≥50 %) tumor programmed death ligand 1 (PD-L1) expression demonstrated longer median OS vs those with low expression. Among 3041 patients receiving I-O monotherapy, median OS was 11.3 (95 % CI, 9.8-12.8) months in patients with squamous NSCLC (n=875) and 14.1 (95 % CI, 12.4-15.8) months in those with non-squamous disease (n=2166). OS benefit appeared to be greatest in the ≥50 % tumor PD-L1 expression group of the non-squamous cohort.

CONCLUSION

Survival estimates were generally lower than those reported in pivotal clinical trials. These findings indicate that there remains room for improvement of real-world survival outcomes in patients with advanced NSCLC who receive 1L I-O-based regimens and for identification of subgroups of patients not benefitting from treatment with current I-O regimens.

Prognostic role of serum thymidine kinase 1 kinetics during neoadjuvant chemotherapy for early breast cancer

Background

Emerging data support the use of thymidine kinase 1 (TK1) activity as a prognostic marker and for monitoring of response in breast cancer (BC). The long-term prognostic value of TK1 kinetics during neoadjuvant chemotherapy is unclear, which this study aimed to elucidate.

Methods

Material from patients enrolled to the single-arm prospective PROMIX trial of neoadjuvant epirubicin, docetaxel and bevacizumab for early BC was used. Ki67 in baseline biopsies was assessed both centrally and by automated digital imaging analysis. TK1 activity was measured from blood samples obtained at baseline and following two cycles of chemotherapy. The associations of TK1 and its kinetics as well as Ki67 with event-free survival and overall survival (OS) were evaluated using multivariable Cox regression models.

Results

Central Ki67 counting had excellent correlation with the results of digital image analysis (r = 0.814), but not with the diagnostic samples (r = 0.234), while it was independently prognostic for worse OS [adjusted hazard ratio (HR_adj) = 2.72, 95% confidence interval (CI) 1.19-6.21, P = 0.02]. Greater increase in TK1 activity after two cycles of chemotherapy resulted in improved event-free survival (HR_adj = 0.50, 95% CI 0.26-0.97, P = 0.04) and OS (HR_adj = 0.46, 95% CI 0.95, P = 0.04). There was significant interaction between the prognostic value of TK1 kinetics and Ki67 (p_interaction 0.04).

Conclusion

Serial measurement of serum TK1 activity during neoadjuvant chemotherapy provides long-term prognostic information in BC patients. The ease of obtaining serial samples for TK1 assessment motivates further evaluation in larger studies.

•

This is a correlative analysis of a prospective phase II study on neoadjuvant chemotherapy for breast cancer.

•

Serial measurement of serum TK1 activity during treatment provides independent long-term prognostic information.

•

We demonstrate the validity and clinical utility of both central and automated image analysis-based Ki67 assessment.

•

Finally, we explore the biologic correlations between TK1 and Ki67.

Artificial intelligence as the next step towards precision pathology

Pathology is the cornerstone of cancer care. The need for accuracy in histopathologic diagnosis of cancer is increasing as personalized cancer therapy requires accurate biomarker assessment. The appearance of digital image analysis holds promise to improve both the volume and precision of histomorphological evaluation. Recently, machine learning, and particularly deep learning, has enabled rapid advances in computational pathology. The integration of machine learning into routine care will be a milestone for the healthcare sector in the next decade, and histopathology is right at the centre of this revolution. Examples of potential high-value machine learning applications include both model-based assessment of routine diagnostic features in pathology, and the ability to extract and identify novel features that provide insights into a disease. Recent groundbreaking results have demonstrated that applications of machine learning methods in pathology significantly improves metastases detection in lymph nodes, Ki67 scoring in breast cancer, Gleason grading in prostate cancer and tumour-infiltrating lymphocyte (TIL) scoring in melanoma. Furthermore, deep learning models have also been demonstrated to be able to predict status of some molecular markers in lung, prostate, gastric and colorectal cancer based on standard HE slides. Moreover, prognostic (survival outcomes) deep neural network models based on digitized HE slides have been demonstrated in several diseases, including lung cancer, melanoma and glioma. In this review, we aim to present and summarize the latest developments in digital image analysis and in the application of artificial intelligence in diagnostic pathology.

JAK-STAT Activity in Peripheral Blood Cells and Kidney Tissue in IgA Nephropathy

BACKGROUND AND OBJECTIVES

IgA nephropathy is the most common primary glomerular disease in the world. Marked by mesangial inflammation and proliferation, it generally leads to progressive kidney fibrosis. As the Janus kinase signal transducer and activator of transcription pathway has been implicated as an important mediator of diabetic kidney disease and FSGS, detailed investigation of this pathway in IgA nephropathy was undertaken to establish the basis for targeting this pathway across glomerular diseases.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Well characterized patients with IgA nephropathy and controls were studied, allowing us to compare 77 patients with biopsy-proven IgA nephropathy with 45 healthy subjects. STAT phosphorylation was assessed in peripheral blood monocytes (PBMCs) by phosphoflow before and after cytokine stimulation. Kidney Janus kinase signal transducer and activator of transcription activity was studied by immunofluorescence and by transcriptomic studies. An STAT1 activity score was established using downstream transcriptional targets of pSTAT1 and associated with disease and clinical outcomes.

RESULTS

We found PBMCs to have upregulated pSTAT production at baseline in patients with IgA nephropathy with a limited reserve to respond to cytokine stimulation compared with controls. Increased staining in glomerular mesangium and endothelium was seen for Jak-2 and pSTAT1 and in the tubulointerstitial for JAK2, pSTAT1, and pSTAT3. Activation of the Janus kinase signal transducer and activator of transcription pathway was further supported by increased pSTAT1 and pSTAT3 scores in glomerular and tubulointerstitial sections of the kidney (glomerular activation Z scores: 7.1 and 4.5, respectively; P values: <0.001 and <0.001, respectively). Clinically, phosphoflow results associated with proteinuria and kidney function, and STAT1 activation associated with proteinuria but was not associated with progression.

CONCLUSIONS

Janus kinase signal transducer and activator of transcription signaling was activated in patients with IgA nephropathy compared with controls. There were altered responses in peripheral immune cells and increased message and activated proteins in the kidney. These changes variably related to proteinuria and kidney function.

Folate Intake May Affect Emotional Intelligence (P24-032-19)

Objectives

This observational explores the relationship between different intakes of folate and emotional intelligence (EQ).

Methods

The data for the study came from n = 5003 unique individuals that took the Depression and Anxiety Assessment Test (DAAT) an 85 question questionnaire. EQ was measured by a standardized mini EQ test included in the DAAT. Frequency of folate intake was self-reported and based on dietary and supplemental intake captured using the DAAT. According the answers, intake of folate intake subject were divided as high intake, average intake or poor intake. EQ measures five discrete attributes: knowing and managing one's own emotions, recognizing emotions in others, properly managing one's relationships, and motivation to achieve one's goals and physical health has an effect on it.

Results

From n = 5003 that took the test, n = 2410 (48.1%) reported high folate intake and had a mean EQ of 113.2 (SD: 18) and median of 116. N = 1246 (24.9%) reported average folate intake and had a mean EQ of 104.4 (SD: 18) and median of 104. Those with poor folate intake n = 1347 (29.6%) had a mean EQ of 99.6 (SD: 17) and median of 98. With all subjects (n = 5003) considered together and folate intake translated into a numerical scale between 0 and 1 (poor intake: 1, average: 0.5, high: 0), Pearson's correlation revealed an r-value of 0.316 (P < 0.001) between folate intake frequency and EQ test score.

Conclusions

It seems there is a weak relationship between the consumption of high-folate foods and EQ, though the mechanism for this effect is not known and requires further research. High EQ is important as it has been shown to greatly affect one's personal and professional achievement, better social intercourse and success in life.

Funding Sources

Self funded.

Loss of Sirtuin 1 Alters the Secretome of Breast Cancer Cells by Impairing Lysosomal Integrity

The NAD⁺-dependent deacetylase Sirtuin 1 (SIRT1) is down-regulated in triple-negative breast cancer. To determine the mechanistic basis by which reduced SIRT1 expression influences processes related to certain aggressive cancers, we examined the consequences of depleting breast cancer cells of SIRT1. We discovered that reducing SIRT1 levels decreased the expression of one particular subunit of the vacuolar-type H+ ATPase (V-ATPase), which is responsible for proper lysosomal acidification and protein degradation. This impairment in lysosomal function caused a reduction in the number of multi-vesicular bodies (MVBs) targeted for lysosomal degradation and resulted in larger MVBs prior to their fusing with the plasma membrane to release their contents. Collectively, these findings help explain how reduced SIRT1 expression, by disrupting lysosomal function and generating a secretome comprising exosomes with unique cargo and soluble hydrolases that degrade the extracellular matrix, can promote processes that increase breast-cancer-cell survival and invasion.

JAK-STAT signaling is activated in the kidney and peripheral blood cells of patients with focal segmental glomerulosclerosis

Focal segmental glomerular sclerosis (FSGS) is a devastating disease with limited treatment options and poor prognosis. Activated JAK-STAT signaling has been implicated in other kidney diseases. Since new technologies allow us to better evaluate changes in systemic and renal JAK-STAT activity as it relates to kidney function, we examined this in 106 patients with biopsy-proven FSGS compared to 47 healthy control individuals. Peripheral immune function was assessed in peripheral blood mononuclear cells by phosphoflow studies before and after cytokine stimulation. Kidney JAK-STAT activity was measured by immunofluorescence and by transcriptomics. A STAT1 activity score was calculated by evaluating message status of downstream targets of pSTAT 1. Peripheral blood mononuclear cells were found to be upregulated in terms of pSTAT production at baseline in FSGS and to have limited reserve to respond to various cytokines. Increased staining for components of the JAK-STAT system in FSGS by microscopy was found. Furthermore, we found transcriptomic evidence for activation of JAK-STAT that increased pSTAT 1 and pSTAT 3 in glomerular and tubulointerstitial sections of the kidney. Some of these changes were associated with the likelihood of remission of proteinuria and progression of disease. JAK-STAT signaling is altered in patients with FSGS as compared to healthy controls with activated peripheral immune cells, increased message in the kidney and increased activated proteins in the kidney. Thus, our findings support immune activation in this disease and point to the JAK-STAT pathway as a potential target for treatment of FSGS.

Abstract P2-03-07: Digital image analysis of Ki67 in hot spots is superior to alternative proliferation associated markers in breast cancer

INTRODUCTION

Proliferative activity is one of the most important prognostic parameters in cancer. During the pathological examination of breast tumors, it is routinely evaluated by a count of the number of mitoses. Adding immunohistochemical stains of the nuclear protein Ki67 provides extra prognostic and predictive information. However, the currently used methods for both of these evaluations battle imperfections, primarily in reproducibility. In this study, we make an equally broad and detailed evaluation of mitoses, Ki67 and the more recently described Phosphohistone H3 (PHH3) in primary breast cancer using digital image analysis (DIA). Furthermore, we aim to investigate the prognostic and predictive value of proliferation-associated biomarkers in breast cancer stromal cells in relation to patient outcome.

MATERIALS AND METHODS

Two cohorts of primary breast cancer specimens (total n=297) with clinicopathological data including &gt;10 years survival data, were sectioned and stained for Ki67, PHH3 and pancytokeratin (CKMNF116) and all glass slides were digitally scanned at x20. The DIA software used was the Visiopharm Integrator System (VIS) by Visiopharm A/S, Hoersholm, Denmark. VIS operates by a 'digital fusion' method that automatically excludes non-epithelial tissue restricting the analysis of the biomarkers (Ki67 and PHH3) to CKMNF116 positive cells. Both manual and DIA scores were compared for sensitivity and specificity for the gene expression based Luminal B versus A subtype, for high versus low transcriptomic grade as well as for their prognostic value in terms of Cox regression hazard ratios and breast cancer specific and overall survival. Further, we investigated whether the expression of Ki67 in the tumors' hot spots, invasive edges or as an average across all regions should be assessed for maximum power in relation to these outcomes. In addition, by inverting the DIA algorithm run by the VIS on the same cohorts, the expression of Ki67 and PHH3 was evaluated in the tumor stromal compartment.

RESULTS

Regardless of tumor region, DIA of Ki67 outperformed the other markers in sensitivity and specificity for gene expression subtypes and transcriptomic grade. In contrast to mitotic counts, tumors with high expression of Ki67 as defined by DIA, had significantly increased hazard ratio for all-cause mortality within 10 years from diagnosis. DIA of Ki67 was superior to manual Ki67 and PHH3 evaluations as well as to mitotic counts in terms of separation of patients with poor versus relatively good survival. Finally, we replaced the manual mitotic counts with DIA of Ki67 in hot spots as the marker for proliferation when determining histological grade. This increased the differences in estimated mean overall survival between the highest and lowest grades and added significantly more prognostic information to the classic Nottingham histological grade.

CONCLUSIONS

We conclude that digital image analysis of Ki67 in hot spots should be suggested as the marker of choice for proliferative activity in breast cancer.

Citation Format: Robertson S, Stålhammar G, Wedlund L, Gholizadeh S, Lippert M, Rantaleinen M, Bergh J, Hartman J. Digital image analysis of Ki67 in hot spots is superior to alternative proliferation associated markers in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-07.

FSGS as an Adaptive Response to Growth-Induced Podocyte Stress

Glomerular sclerotic lesions develop when the glomerular filtration surface area exceeds the availability of podocyte foot process coverage, but the mechanisms involved are incompletely characterized. We evaluated potential mechanisms using a transgenic (podocin promoter-AA-4E-BP1) rat in which podocyte capacity for hypertrophy in response to growth factor/nutrient signaling is impaired. FSGS lesions resembling human FSGS developed spontaneously by 7 months of age, and could be induced earlier by accelerating kidney hypertrophy by nephrectomy. Early segmental glomerular lesions occurred in the absence of a detectable reduction in average podocyte number per glomerulus and resulted from the loss of podocytes in individual glomerular capillary loops. Parietal epithelial cell division, accumulation on Bowman's capsule, and tuft invasion occurred at these sites. Three different interventions that prevented kidney growth and glomerular enlargement (calorie intake reduction, inhibition of mammalian target of rapamycin complex, and inhibition of angiotensin-converting enzyme) protected against FSGS lesion development, even when initiated late in the process. Ki67 nuclear staining and unbiased transcriptomic analysis identified increased glomerular (but not podocyte) cell cycling as necessary for FSGS lesion development. The rat FSGS-associated transcriptomic signature correlated with human glomerular transcriptomes associated with disease progression, compatible with similar processes occurring in man. We conclude that FSGS lesion development resulted from glomerular growth that exceeded the capacity of podocytes to adapt and adequately cover some parts of the filtration surface. Modest modulation of the growth side of this equation significantly ameliorated FSGS progression, suggesting that glomerular growth is an underappreciated therapeutic target for preservation of renal function.

Decorrelation correction for nanoparticle tracking analysis of dilute polydisperse suspensions in bulk flow

Nanoparticle tracking analysis, a multiprobe single particle tracking technique, is a widely used method to quickly determine the concentration and size distribution of colloidal particle suspensions. Many popular tools remove non-Brownian components of particle motion by subtracting the ensemble-average displacement at each time step, which is termed dedrifting. Though critical for accurate size measurements, dedrifting is shown here to introduce significant biasing error and can fundamentally limit the dynamic range of particle size that can be measured for dilute heterogeneous suspensions such as biological extracellular vesicles. We report a more accurate estimate of particle mean-square displacement, which we call decorrelation analysis, that accounts for correlations between individual and ensemble particle motion, which are spuriously introduced by dedrifting. Particle tracking simulation and experimental results show that this approach more accurately determines particle diameters for low-concentration polydisperse suspensions when compared with standard dedrifting techniques.

Abstract P6-01-04: Evolutionary analyses of matched primary and metastatic breast cancer reveal both linear and parallel progression with lack of axillary lymph node involvement

This abstract was withdrawn by the authors.

Abstract P2-03-03: Molecular differences between screen-detected and interval breast cancers are largely explained by PAM50 subtypes

Purpose:Interval breast cancer is of clinical interest as it exhibits an aggressive phenotype and evades detection by screening mammography. A comprehensive picture of somatic changes that drive tumors to become symptomatic in the screening interval can improve understanding of the biology underlying these aggressive tumors.

Experimental design:Initiated in April 2013, Clinical Sequencing of Cancer in Sweden (Clinseq) is a scientific and clinical platform for the genomic profiling of cancer. The breast cancer pilot study consisted of women diagnosed with breast cancer between 2001-2012 in the Stockholm/Gotland regions. A subset of 318 breast tumors were sequenced, of which 113 were screen-detected and were 60 interval cancers.We applied targeted deep-sequencing of cancer-related genes, low-pass whole-genome sequencing and RNA-sequencing technology to characterize somatic differences in the genomic and transcriptomic architecture by interval cancer status. Mammographic density and PAM50 molecular subtypes were considered.

Results:In the crude analyses, TP53, PPP1R3A, and KMT2B were significantly more frequently mutated in interval cancers than in screen-detected cancers. Acquired somatic copy number aberrations with a frequency difference of at least 15% between the two groups included gains in 17q23-q25.3 and losses in 16q24.2. Gene expression analysis identified 447 significantly differentially expressed genes, of which 120 were replicated in an independent microarray dataset. After adjusting for PAM50, most differences were no longer significant.

Conclusions: Molecular differences by interval cancer status were observed, but they were largely explained by PAM50 subtypes. This work offer new insights into the biological differences between the two tumor groups.

Translational relevance: Although screen-detected cancers are biologically distinct from interval cancers in terms of somatic mutations, copy number aberrations and gene expression, most of the differences are no longer significant after adjusting for breast cancer intrinsic subtypes (PAM50). We also show that the molecular differences appear to form a spectrum from less aggressive (screen-detected) to more aggressive (interval) manifestations of the disease, which can be characterized by PAM50 subtypes, namely, luminal A, luminal B, HER2-enriched and basal-like, in that order. This work clarifies the picture on what type of breast cancer we are likely to identify through population-based screening, and what type of cancer we are likely to miss. Current knowledge of PAM50 subtype-specific risk factors need to be expanded as our findings might influence how we screen women with a higher risk of basal-like breast cancer for example, beyond known risk groups BRCA1 mutation carriers and women of African-American descent.

Citation Format: Czene K, Ivansson E, Klevebring D, Tobin NP, Lindström LS, Holm J, Prochazka G, Hilliges C, Palmgren J, Törnberg S, Humphreys K, Hartman J, Frisell J, Rantalainen M, Lindberg J, Hall P, Bergh J, Grönberg H, Li J. Molecular differences between screen-detected and interval breast cancers are largely explained by PAM50 subtypes [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 P2-03-03.

Neurobiological Effects of Morphine after Spinal Cord Injury

Opioids and non-steroidal anti-inflammatory drugs are used commonly to manage pain in the early phase of spinal cord injury (SCI). Despite its analgesic efficacy, however, our studies suggest that intrathecal morphine undermines locomotor recovery and increases lesion size in a rodent model of SCI. Similarly, intravenous (IV) morphine attenuates locomotor recovery. The current study explores whether IV morphine also increases lesion size after a spinal contusion (T12) injury and quantifies the cell types that are affected by early opioid administration. Using an experimenter-administered escalating dose of IV morphine across the first seven days post-injury, we quantified the expression of neuron, astrocyte, and microglial markers at the injury site. SCI decreased NeuN expression relative to shams. In subjects with SCI treated with IV morphine, virtually no NeuN⁺ cells remained across the rostral-caudal extent of the lesion. Further, whereas SCI per se increased the expression of astrocyte and microglial markers (glial fibrillary acidic protein and OX-42, respectively), morphine treatment decreased the expression of these markers. These cellular changes were accompanied by attenuation of locomotor recovery (Basso, Beattie, Bresnahan scores), decreased weight gain, and the development of opioid-induced hyperalgesia (increased tactile reactivity) in morphine-treated subjects. These data suggest that morphine use is contraindicated in the acute phase of a spinal injury. Faced with a lifetime of intractable pain, however, simply removing any effective analgesic for the management of SCI pain is not an ideal option. Instead, these data underscore the critical need for further understanding of the molecular pathways engaged by conventional medications within the pathophysiological context of an injury.

3D imaging using combined neutron-photon fan-beam tomography: A Monte Carlo study

The application of combined neutron-photon tomography for 3D imaging is examined using MCNP5 simulations for objects of simple shapes and different materials. Two-dimensional transmission projections were simulated for fan-beam scans using 2.5MeV deuterium-deuterium and 14MeV deuterium-tritium neutron sources, and high-energy X-ray sources, such as 1MeV, 6MeV and 9MeV. Photons enable assessment of electron density and related mass density, neutrons aid in estimating the product of density and material-specific microscopic cross section- the ratio between the two provides the composition, while CT allows shape evaluation. Using a developed imaging technique, objects and their material compositions have been visualized.

Abstract P6-07-09: Somatic mutations in A kinase anchoring proteins (AKAPs) in metastatic tumors - A potential characteristic of breast cancer metastasis

Introduction

Genomic heterogeneity in primary solid tumors has been extensively studied using deep sequencing technologies during the last decade. The heterogeneity of cancer tumors is today a well-established concept partly reflected in the low number of genes being recurrently mutated in over 10% of the tumors. However, most available data relates to the primary breast cancer tumors and little has been described about the mutational profiles of the metastatic lesions and their relation to its original malignant cell population. Prospective and retrospective studies have demonstrated that altered receptor status in the metastatic lesion occurs at high rates during cancer progression and is additionally affected by adjuvant therapy with major implications for management of the metastatic disease. Here, we report the exome sequences of paired primary and metastatic lesions from ten breast cancer patients.

Results

We found a marked heterogeneity of somatic mutations as well as chromosomal aberrations in the metastatic lesions. A number of mutated genes were enriched in the metastases including, significantly, members of the A-kinase anchoring protein family (AKAPs), p &lt; 0.02; Fisher's exact test.

The enrichment of AKAP mutations in metastatic lesions was confirmed in an independent cohort containing 20 patients with paired primary and metastatic lesions, which showed the same mutational pattern. In total, 14 nonsynonymous mutations were found in ten of the fourteen AKAP family members. Out of the totally 30 patients examined, ten (30%) carried one or more mutations in AKAP genes either in primary tumor, metastasis, or both. In seven of these ten patients, the AKAP mutation was found uniquely in the metastatic lesion.

Several copy number variations (CNV), mostly deletions in regions containing AKAP genes were detected. For example, the down-regulation of AKAP12 is often associated with promoter hypermethylation or loss of its locus 6q24-25.2 and has been associated with tumor progression and metastasis. In our data deletion of the AKAP12 locus is present in six out of twenty patients.

Discussion

AKAPs are members of a protein family acting as anchors for Protein Kinase A (PKA) by specifically associate PKA regulatory subunits to cellular organelles and direct its active signal transduction spatially and temporally. Several of the AKAP members have been associated to cancer development and metastatic spread, mostly based on differential expression and effects on migration in in vitro assays but both polymorphisms and somatic mutations have been reported in human tumors.

Our findings indicate that in metastatic lesions, the primary tumor genome is extensively transformed, with enrichment of mutations in a distinct set of genes. Together, these findings suggest the involvement of AKAPs in the metastatic process and provide a potential avenue for targeted therapy directed at metastatic breast cancer. Molecular and genetic characterization of the metastatic lesions is not only important in the clinical setting but should also provide the means to reveal genetic patterns specific for the disseminated malignancy.

Citation Format: Kjällquist U, Erlandsson R, Alkodsi A, Tobin N, Karlsson E, Hatschek T, Hartman J, Linnarsson S, Bergh J. Somatic mutations in A kinase anchoring proteins (AKAPs) in metastatic tumors - A potential characteristic of breast cancer metastasis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-07-09.

[A toddler with a red, swollen arm after vaccination]

An almost 4-year-old girl developed swelling, redness and pruritus of the vaccinated arm 2 days after immunisation with DPTP. The girl had no fever. The reaction spread around the upper arm and the elbow. We made the diagnosis of 'extensive limb swelling'. The symptoms disappeared spontaneously within 1 week.

Abstract P4-07-12: miR-206 inhibits cell migration through direct targeting of the actin-binding protein coronin 1C in triple-negative breast cancer

Patients with triple-negative breast cancer (TNBC) have an overall poor prognosis, which is primarily due to a high metastatic capacity of these tumors. Novel therapeutic approaches to target the signaling pathways that promote metastasis are desirable, in order to improve the outcome of TNBC patients. A loss of function of a microRNA, miR-206, is related to increased metastasis potential in breast cancers but the mechanism remains to be elucidated. In this study, we show that miR-206 was decreased in TNBC clinical tumor samples and cell lines whereas one of its predicted targets, actin-binding protein CORO1C, was increased. Expression of miR-206 significantly reduced proliferation by inducing a G1-S cell cycle arrest and migration and also repressed CORO1C mRNA and protein levels. We demonstrate that miR-206 interacts with the 3’-untranslated region (3’-UTR) of CORO1C and regulates this gene post-transcriptionally. Further, silencing of CORO1C reduced tumor cell migration and affected the actin skeleton and cell morphology, similar to miR-206 expression, but did not reduce proliferation. Our findings suggest that miR-206 targets CORO1C in TNBC cells, thereby affecting the actin filaments which results in a repressed tumor cell migration. This pathway is a novel mechanism offering a mechanistic basis whereby the metastatic potential of TNBC tumors could be targeted.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-07-12.

Abstract OT1-2-03: A prospective randomized phase II study to identify predictive biomarkers and mechanisms of resistance in patients with HER2-negative metastatic breast cancer treated with the combination of bevacizumab and paclitaxel

Background

Several phase III trials have evaluated the combination of bevacizumab and chemotherapy in patients with metastatic breast cancer (MBC). These individual studies as well as a meta-analysis indicate high response rates (RR) and increased progression-free survival (PFS), however no significant gain of overall survival (OS) by the addition of bevacizumab to chemotherapy. To date, there are no methods to reliably select patients with MBC that benefit from treatment with bevacizumab.

Trial design

This project is a prospective, randomized, 2-arm, open-label, single-center, phase II trial aiming to identify predictive markers and mechanisms of resistance to bevacizumab in MBC by longitudinal biopsies and functional imaging. The study will be initiated with a non-randomized, feasibility stage including ten patients who will be treated with bevacizumab and paclitaxel, in order to determine the safety of metastatic tumor biopsies during therapy with bevacizumab. In a second phase, 20 patients will be randomized (1:1) between two treatment arms: Paclitaxel 80 mg / m2 weekly with or without bevacizumab 15 mg / kg every 3 weeks.

Mandatory, repeated peripheral blood sampling and fine needle aspiration biopsies (FNAB) will be collected at baseline, at day 4 after the first cycle and at progression. At baseline, a core biopsy will be obtained as well. Patients will also undergo two 18F]-fluoro-L-thymidine (FLT) Positron Emission Tomography (PET)/CT scans (18F-FLT PET/CT), at baseline and at day 4 after the first cycle.

Eligibility criteria

Eligible are patients aged 18-70 years, with newly diagnosed HER2-negative MBC (stage IV or recurrent) that are candidates for chemotherapy (ECOG 0-2), with measurable disease and at least one lesion that is accessible for biopsy. Adequate bone marrow, hepatic and renal function are required, as well as absence of thromboembolic disease, bleeding diathesis or second concurrent malignancy. No previous systemic treatment for MBC is allowed.

Specific aims

1. To assess early therapeutic response to bevacizumab in MBC by whole-exome sequencing and gene expression of serial metastatic biopsies and functional imaging.

2. To identify potential biomarkers present in plasma that can be used for patient selection or for monitoring therapy with bevacizumab in MBC.

3. To explore mutations and gene expression alterations as mechanisms of resistance to bevacizumab in MBC.

Statistical methods

The main objective of the study is exploratory. For most of the planned analyses, each patient will serve as her own control and baseline values of potential biomarkers will be compared in pairs with intra-patient, longitudinal samples, which significantly increases the statistical power.

For the identification of biomarkers, the results of the molecular analyses will be correlated with clinical outcome measurements including RR, PFS, and OS.

Present accrual and target accrual.

The trial was opened for inclusion in May 2013 and one patient has been accrued by June 1st 2013. A total of 30 patients will be included during a period of 2 years.

Contact:

Principal Investigator: Theodoros.Foukakis@ki.se; Study Director: Jonas.Bergh@ki.se.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT1-2-03.

Comparison of anesthesia technique on outcomes of endovascular repair of abdominal aortic aneurysms: a five-year review of monitored anesthesia care with local anesthesia vs. general or regional anesthesia

AIM

This retrospective study compares outcomes according to anesthesia technique of a consecutive series of 48 endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) performed by one vascular surgeon at a single institution over a five-year period.

METHODS

Demographic, pre-procedure, procedure-related, recovery room, surgical unit, and hospital outcome variables were extracted and compared between patients receiving general or regional anesthesia and those receiving monitored anesthesia care (MAC) with local anesthesia.

RESULTS

Eighteen (37.5%) patients received general or regional anesthesia and 30 (62.5%) patients received MAC with local anesthesia. No statistically significant differences in demographics or pre-procedure variables were calculated between study groups. Conversion to open repair was not required, no intraoperative complications occurred, and conversion from MAC with local anesthesia to general anesthesia was not required. The only significant differences calculated were in length of anesthesia (P=0.001, power 0.962) and time to ambulation (P=0.004, power 0.871), with significantly lower median times in the MAC and local anesthesia groups. Other than one (2.1%) patient in the MAC with local anesthesia group whose death was related to history of severe coronary disease, no other acute medical complications occurred.

CONCLUSION

The results of this study suggest that use of MAC with local anesthesia during EVAR of AAAs is comparable to general and regional anesthesia in terms of safety and efficacy. Furthermore, MAC with local anesthesia confers additional outcome benefits versus general and regional anesthesia, as it is less invasive, offers greater hemodynamic stability, and enables better communication with the patient.

Identifying subtypes of patients with neovascular age-related macular degeneration by genotypic and cardiovascular risk characteristics

BACKGROUND

One of the challenges in the interpretation of studies showing associations between environmental and genotypic data with disease outcomes such as neovascular age-related macular degeneration (AMD) is understanding the phenotypic heterogeneity within a patient population with regard to any risk factor associated with the condition. This is critical when considering the potential therapeutic response of patients to any drug developed to treat the condition. In the present study, we identify patient subtypes or clusters which could represent several different targets for treatment development, based on genetic pathways in AMD and cardiovascular pathology.

METHODS

We identified a sample of patients with neovascular AMD, that in previous studies had been shown to be at elevated risk for the disease through environmental factors such as cigarette smoking and genetic variants including the complement factor H gene (CFH) on chromosome 1q25 and variants in the ARMS2/HtrA serine peptidase 1 (HTRA1) gene(s) on chromosome 10q26. We conducted a multivariate segmentation analysis of 253 of these patients utilizing available epidemiologic and genetic data.

RESULTS

In a multivariate model, cigarette smoking failed to differentiate subtypes of patients. However, four meaningfully distinct clusters of patients were identified that were most strongly differentiated by their cardiovascular health status (histories of hypercholesterolemia and hypertension), and the alleles of ARMS2/HTRA1 rs1049331.

CONCLUSIONS

These results have significant personalized medicine implications for drug developers attempting to determine the effective size of the treatable neovascular AMD population. Patient subtypes or clusters may represent different targets for therapeutic development based on genetic pathways in AMD and cardiovascular pathology, and treatments developed that may elevate CV risk, may be ill advised for certain of the clusters identified.

Ultrasonographic and DSCT scan analysis of single lima versus arterial T grafts 12 years after surgery

AIM

The aim of this study was to investigate long-term graft outcome in patients with left internal mammary artery to left anterior descending coronary artery (LIMA-LAD) and T-grafts by ultrasonography and dual source computed tomography (DSCT) and to analyse if ultrasonography can determine graft patency.

METHODS

Thirty-two patients, 28 males, 50.8+/-8.8 years at operation, were studied. Fifteen patients with single LIMA-LAD and additional vein grafts (group I) and 17 patients with LIMA-free right internal mammary artery (FRIMA) T-grafts (group II) underwent DSCT, transthoracic ultrasonography of the LIMA and an electrocardiogram. Differences were tested with unpaired and paired t tests.

RESULTS

In group I, 4.1+/-1.1 and in group II, 4.5+/-1.1 anastomoses/patients were performed. DSCT showed three string sign LIMA (20%) grafts and six occluded venous anastomoses (13%) in group I and three (distal) string sign LIMA grafts (18%), seven occluded LIMA anastomoses (23%) and nine occluded FRIMA anastomoses (23%) in group II. Ultrasonographic variables in the proximal part of the LIMA graft did not differ between the groups. No effect was found for proximal string sign LIMA grafts in ultrasonographic graft performance.

CONCLUSION

Ultrasonography cannot distinguish between string sign and patent single LIMA or T-grafts nor demonstrate distal anastomosis patency in T-grafts 12 years after surgery.