Abstract OT3-02-07: Neo-DDRD: A biomarker-driven neoadjuvant feasibility study in breast cancer

Background

Anthracycline-based chemotherapy reduces the risk of early breast cancer recurrence but to date it has not been possible to predict which patients specifically benefit from this treatment. The Almac DDRD assay, a 44 gene signature, has been developed to detect DNA damage response deficiency (DDRD) within breast and other cancer types. The DDRD assay has been shown to predict benefit from DNA damaging chemotherapy in retrospective analyses in neoadjuvant and adjuvant settings (Mulligan et al, JNCI 2014). This pilot study aims to prospectively evaluate the feasibility and utility of this signature in the neoadjuvant setting in breast cancer. It will inform the design of a phase II randomised study where the DDRD assay will be utilised to guide neoadjuvant chemotherapy selection.

Study design

A single-centre, non-randomised feasibility study of 30 women with a histologically confirmed diagnosis of breast cancer, where neoadjuvant chemotherapy is the treatment modality of choice.

Inclusion criteria:

Age >18 years

Early (T1-2, N0-1), locally advanced or inflammatory breast cancer

Normal left ventricular function, haematological and biochemical parameters

ECOG PS 0-1

Exclusion criteria:

Metastatic disease

Bilateral breast cancer

Pregnancy/breastfeeding

Inability to give informed consent

At diagnosis, patients consented to providing two core needle biopsies in addition to a diagnostic biopsy. Axillary nodal status was determined by axillary ultrasound, fine needle aspiration cytology, and pre-treatment sentinel node biopsy if pre-operative axillary staging was negative.

Chemotherapy was administered as per standard institutional practice: 6 cycles fluourouracil, epirubicin and cyclophosphamide (FEC) in node-negative patients; 3 cycles of FEC followed by 3 cycles of docetaxel in node positive patients. Neoadjuvant trastuzumab was given in Her2 positive patients. Imaging (mammography and ultrasound) was repeated after three cycles, and repeat FFPE and snap frozen core biopsies undertaken. At conclusion of treatment, patients underwent surgery as appropriate (mastectomy or breast conservation at the discretion of the operating surgeon), with axillary node clearance for patients who were node positive at diagnosis. Further biopsies (FFPE and fresh frozen) were taken intra-operatively. Plasma samples were obtained at diagnosis, mid-treatment and surgery. Pathological reporting of the surgical specimen was standardised using the residual cancer burden (RCB) reporting system.

Aims

· To assess the feasibility of carrying out the DDRD assay on diagnostic core biopsy specimens

· To evaluate the turn-around time for the assay to assess feasibility of integration into the breast cancer treatment pathway

· To assess the correlation of DDRD assay scores and pathological tumour response

· Exploratory biomarker analysis will be carried out within Queen's University, Belfast, including:

o correlation of DDRD score with changes in Ki67 protein level after three cycles of chemotherapy

o exploratory analysis of chemokine expression in peripheral plasma samples, and correlation with pathological response to treatment

Accrual

The study opened in April 2014. Accrual to date is 14 patients.

Citation Format: McIntosh SA, Parkes EE, James CR, Lioe T, Lowry K, Keating KE, Khambata-Ford S, Kennedy RD. Neo-DDRD: A biomarker-driven neoadjuvant feasibility study in breast cancer. [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 OT3-02-07.

P5-09-04: Predictors of Malignancy and Surgical Outcomes Following Indeterminate Core Needle Biopsy in the British Breast Screening Programme

Background: The National Health Service Breast Screening Programme (NHSBSP) invites women between 50 and 70 years for mammography every three years, with abnormal imaging leading to further assessment. Core needle biopsy (CNB) is the standard for obtaining a definitive pre-operative diagnosis. However a proportion of CNBs will be reported as showing indeterminate pathology, with uncertain malignant potential. This necessitates surgical diagnostic excision biopsy, with attendant potential morbidity, and highlights the importance of pre-operative diagnosis. This study aimed to categorise the histological lesions prompting B3 classification arising within a screening programme, and to quantify the definitive surgical outcomes following excision biopsy.

Material and Methods: Data was collected retrospectively from January 2000 — December 2010, including demographic details, radiological presentation, relevant clinical findings, results of preoperative investigations, reports of diagnostic excision biopsy and subsequent surgical management. Patients were included if they had a B3 CNB result and subsequent excision biopsy, following attendance for screening mammography. Primary outcome was classification of B3 lesions and positive predictive values (PPV) for malignancy. Secondary outcomes were subsequent surgical procedures.

Results: There were 239 B3 lesions, representing 7.1% of all CNB carried out within the screening programme. Mean patient age was 55.6 years, and median lesion size was 14.5 mm (range: 4–25mm). Eighty seven lesions (36.4%) were malignant on excision: 28 (11.7%) invasive and 52 (21.8%) in situ. Lesion specific PPVs for malignancy were as follows: phyllodes tumour 50.0%, atypical ductal hyperplasia 40.0%, columnar cell lesion 40.0%, papillary lesion 26.7%, lobular neoplasia in situ 26.7%, and radial scar/complex sclerosing lesions (RS/CSL) 25.9%. The PPV of RS/CSL with atypia was 65.2%, and without 25.8%. Of 87 malignant cases, 55 (63.2%) went on to have a further surgery. 27 (50.9%) had re-excision of surgical margins, 10 (18.2%) had a mastectomy, 8 (14.5%) had a wide local excision, 2 had an axillary biopsy and one patient had a quadrantectomy. 18 patients had two further operations, the second was most commonly an axillary clearance, and 3 patients had three further operations. Discussion: B3 lesions are heterogeneous in nature, and continue to mandate surgical excision, demonstrated by a PPV of 36.4%, the highest reported figure in the literature to date. B3 CNB represents a significant surgical workload, demonstrated by the fact that 63.2% cases go on to have further surgery, and that 8.8% will require more than one further operation. Currently there is no pre-operative investigation that reliably predicts the likelihood of B3 associated malignancy. It has been demonstrated that the use of large volume vacuum assisted biopsy can reduce the rate of under diagnosis of both in situ and invasive malignancy, and this would clearly reduce the requirement for repeated surgery reported in this study.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-09-04.

Kaposi's sarcoma-associated herpesvirus viral interferon regulatory factor-2 inhibits type 1 interferon signalling by targeting interferon-stimulated gene factor-3

Kaposi's sarcoma-associated herpesvirus (KSHV) encodes four viral interferon regulatory factors (vIRF-1-4). We investigated the mechanism and consequences of vIRF-2-mediated inhibition of interferon-response element signalling following type I interferon (IFN) induction. Western blot and electrophoretic mobility-shift assays identified the interferon-stimulated gene factor-3 (ISGF-3) components STAT1 and IRF-9 as the proximal targets of vIRF-2 activity. The biological significance of vIRF-2 inhibition of ISGF-3 was demonstrated by vIRF-2-mediated rescue of the replication of the IFN-sensitive virus encephalomyocarditis virus. This study provides both a mechanism and evidence for KSHV vIRF-2-mediated suppression of the consequences of type 1 IFN-induced signalling.

Immunovirological correlates in human rabies treated with therapeutic coma

A 37-year-old woman was admitted to hospital and over the next 5 days developed a progressive encephalitis. Nuchal skin biopsy, analyzed using a Rabies TaqMan(c) PCR, demonstrated rabies virus RNA. She had a history in keeping with exposure to rabies whilst in South Africa, but had not received pre- or post-exposure prophylaxis. She was treated with a therapeutic coma according to the "Milwaukee protocol," which failed to prevent the death of the patient. Rabies virus was isolated from CSF and saliva, and rabies antibody was demonstrated in serum (from day 11 onwards) and cerebrospinal fluid (day 13 onwards). She died on day-35 of hospitalization. Autopsy specimens demonstrated the presence of rabies antigen, viral RNA, and viable rabies virus in the central nervous system.

Herpes simplex type 1 shedding is associated with reduced hospital survival in patients receiving assisted ventilation in a tertiary referral intensive care unit

The impact of shedding of herpes simplex virus type 1 (HSV-1) on hospital survival of patients receiving assisted ventilation in an adult tertiary referral, acute trauma intensive care unit was assessed. The study was designed to address a clinical impression linking HSV-1 recovery with poor survival. Two hundred and forty-one males and 152 females were enrolled into a longitudinal cohort study. Combined throat swabs and tracheal secretions were tested for HSV-1 shedding using a nested nucleic acid amplification protocol; patients were ranked as nonshedders, shedders, and high-level shedders. Nonparametric analysis assessed the impact of shedding on hospital survival and logistic regression measured the confounding influence of sex, age, and the Acute Physiology, Age and Chronic Health Evaluation (APACHE II) score. Linear-by-linear association determined the influence of the level of shedding on hospital survival. The observed mortality rate was 113/393 (28.8%). Patients shedding HSV-1 106/393 (27%) had a significant reduction in hospital survival 66/106 (62%) in HSV-1 shedders compared with 217/287 (75.6%) in nonshedders (P = 0.002). This difference remained significant when adjusted for age and sex (P = 0.026). Respective mortality figures for HSV-1 shedders and nonshedders were 43/106 (40.6%) and 70/287 (24.4%) (P = 0.002). HSV-1 shedding was associated with a significant reduction in hospital survival amongst patients receiving assisted ventilation. Hospital mortality in HSV-1 shedders was increased by 16.2% over nonshedders. The role of HSV-1 in this setting needs to be addressed.

Neurotrophin receptor expression and responsiveness by postnatal cerebral oligodendroglia

The low affinity neurotrophin receptor (p75(NTR)) is implicated in promoting oligodendrocytic death after nerve growth factor (NGF) stimulation but NGF and neurotrophin-3 (NT-3) can also potentiate oligodendrocytic survival. We show regional variability in p75(NTR) expression within the central nervous system of the postnatal rat; expression is readily detectable by immunohistochemistry upon a subset of CNPase-positive oligodendroglia in optic nerve but not within the cerebrum. Nevertheless, oligodendroglia isolated from the cerebrum and cultured for 16 hours express p75(NTR) as well as the trkC but not the TrkA gene. Viability was not, however, influenced by exposure to either NGF or NT-3. Cells overexpressing p75(NTR) remained unresponsive to NGF but exhibited potentiated survival with NT-3, correlating with the differential expression profile of their high affinity receptors.

Radiologic case study. Pigmented villonodular synovitis

Pigmented villonodular synovitis is a benign, locally aggressive disorder characterized by a unique clinical radiographic, and histopathologic presentation. While it is considered to be a rare disorder, a delay in diagnosis and treatment can potentially result in severe disruption of joint function due to subchondral invasion. Once the diagnosis is confirmed, treatment should consist of complete synovectomy. Recurrence is common, but malignant transformation is rare. The etiology of PVNS is still unknown, and perhaps its future discovery will assist in the definitive treatment of this disorder.

Course and outcome of IVF pregnancies and spontaneous conceptions within an IVF setting

The study determines mortality and morbidity levels during pregnancy and the perinatal period in those conceiving through IVF in the Republic of Ireland in comparison with other parts of the world and a peer infertile group conceiving spontaneously whilst on the IVF clinic books. Six hundred and sixty couples had 187 IVF pregnancies from whom 220 babies were born to 151 deliveries. There were also 78 spontaneous conceptions which produced 78 offspring from 73 deliveries. The majority had trouble free pregnancies. The incidence of all complications was less than has been reported elsewhere. Of the IVF group, 16.5% aborted completed as did 5% of the spontaneous conceptions. A further 7% and 3.8%, respectively, aborted one sac of a multiple pregnancy. Of the IVF deliveries, 35.8% were multiple as were 6.8% of the spontaneous conceptions. Higher order multiple presence detrimentally influenced delivery mode, gestational age and birth weights in the IVF group. Of IVF patients, 55.7% were section deliveries as were 10.9% of the spontaneous conceptions. Incidence of IVF-group significant congenital abnormality was 1.8%. The perinatal mortality rate was 4.2 per 1000 births. This series suggests the final take-home baby outlook of 81% from conception by IVF is not as poor as previously portrayed. However, attention should be given to abortion, section and multiple pregnancy rates.

Selective decontamination of the digestive tract: a stratified, randomized, prospective study in a mixed intensive care unit

To evaluate the use of selective decontamination of the digestive tract (SDD) (polymyxin, amphotericin, tobramycin, and intravenous cefotaxime) in a mixed intensive care unit, we performed a stratified, randomized, prospective study. The 331 patients were recruited over an 18-month period, with 256 patients remaining more than 48 hours. Stratification by acute physiology and chronic health evaluation (APACHE II) preceded randomization to control (standard antibiotic therapy) or treatment (SDD) groups. Nosocomial infection was significantly reduced in the SDD group (16.7%; 21 of 126 patients) compared with the control group (30.8%; 40 of 130 patients; p = 0.008). No difference was found in overall mortality rate or length of stay between the two groups. Those patients with admission APACHE II scores 10 to 19 demonstrated the most significant reduction in nosocomial infection (23 of 70 control vs 13 of 76 SDD; p = 0.03) and mortality (15 of 70 control vs 8 of 76 SDD; p = 0.07). Emergence of multiresistant microorganisms was not a clinical problem, but a definite change occurred in the ecology of environmental and colonizing bacteria. With the exception of cefotaxime, a reduction was noted in systemic antibiotic usage in the SDD group. We conclude that SDD is useful in selected patients in a mixed intensive care unit.