COVID-19 vaccine immune response in patients with plasma cell dyscrasia: a systematic review

Background

Patients with plasma cell dyscrasia are at a higher risk of developing a severe Coronavirus-2019 (COVID-19) infection. Here we present a systematic review of clinical studies focusing on the immune response to the COVID-19 vaccination in patients with plasma cell dyscrasia.

Objectives

This study aims to evaluate the immune response to COVID-19 vaccines in patients with plasma cell dyscrasia and to utilize the results to improve day-to-day practice.

Design

Systematic Review.

Methods

Online databases (PubMed, CINAHL, Ovid, and Cochrane) were searched following the preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines. Only articles published in the English language were included. Out of 59 studies, nine articles (seven prospective and two retrospective studies) were included in this systematic review. Abstracts, case reports, and case series were excluded.

Results

In all nine studies (N = 1429), seroconversion post-vaccination was the primary endpoint. Patients with plasma cell disorders had a lower seroconversion rate compared to healthy vaccinated individuals and the overall percentage of seroconversion ranged between 23% and 95.5%. Among patients on active therapy, lower seroconversion rates were seen on an anti-CD38 agent, ranging from 6.5 up to 100%. In addition, a significantly lower percentage was recorded in older patients, especially in those aged equal to or greater than 65 years and those who have been treated with multiple therapies previously. Only one study reported a statistically significant better humoral response rate with the mRNA vaccine compared to ADZ1222/Ad26.Cov.S.

Conclusion

Variable seropositive rates are seen in patients with plasma cell dyscrasia. Lower rates are reported in patients on active therapy, anti-CD38 therapy, and elderly patients. Hence, we propose patients with plasma cell dyscrasias should receive periodic boosters to maintain clinically significant levels of antibodies against COVID-19.

Registration

PROSPERO ID: CRD42023404989.

Urothelial Bladder Cancer: Genomic Alterations in Fibroblast Growth Factor Receptor

BACKGROUND AND OBJECTIVE

Genomic alterations in fibroblast growth factor receptor (FGFR) genes have been linked to a reduced response to immune checkpoint inhibitors. Some of the immune microenvironment of urothelial bladder cancer (UBC) could be distorted because of the inhibition of interferon signaling pathways. We present a landscape of FGFR genomic alterations in distorted UBC to evaluate the immunogenomic mechanisms of resistance and response.

METHODS

There were 4035 UBCs that underwent hybrid, capture-based comprehensive genomic profiling. Tumor mutational burden was determined in up to 1.1 Mbp of sequenced DNA and microsatellite instability was determined in 114 loci. Programmed death ligand expression in tumor cells was assessed by immunohistochemistry (Dako 22C3).

RESULTS

The FGFR tyrosine kinases were altered in 894 (22%) UBCs. The highest frequency of alterations was in FGFR genomic alterations with FGFR3 at 17.4% followed by FGFR1 at 3.7% and FGFR2 at 1.1%. No FGFR4 genomic alterations were identified. The age and sex distribution were similar in all groups. Urothelial bladder cancers that featured FGFR3 genomic alterations were associated with lower driver genomic alterations/tumors. 14.7% of the FGFR3 genomic alterations were FGFR3 fusions. Other findings included a significantly higher frequency of ERBB2 amplification in FGFR1/2-altered UBCs compared with FGFR3-altered UBCs. Urothelial bladder cancers with FGFR3 genomic alterations also had the highest frequency of the activating mTOR pathway. FGFR3-altered UBCs also featured significantly higher frequencies of biomarkers associated with a lack of response to immune checkpoint inhibitors including a lower tumor mutational burden, lower programmed death-ligand 1 expression, and higher frequencies of genomic alterations in MDM2. Also linked to IO drug resistance, CDKN2A/B loss and MTAP loss were observed at a higher frequency in FGFR3-driven UBC.

CONCLUSIONS

An increased frequency of genomic alterations is observed in UBC FGFR. These have been linked to immune checkpoint inhibitor resistance. Clinical trials are needed to evaluate UBC FGFR-based biomarkers prognostic of an immune checkpoint inhibitor response. Only then can we successfully incorporate novel therapeutic strategies into the evolving landscape of UBC treatment.

Microbial Influences on Immune Checkpoint Inhibitor Response in Melanoma: The Interplay between Skin and Gut Microbiota

Immunotherapy has revolutionized the treatment of melanoma, but its limitations due to resistance and variable patient responses have become apparent. The microbiota, which refers to the complex ecosystem of microorganisms that inhabit the human body, has emerged as a promising area of research for its potential role in melanoma development and treatment response. Recent studies have highlighted the role of microbiota in influencing the immune system and its response to melanoma, as well as its influence on the development of immune-related adverse events associated with immunotherapy. In this article, we discuss the complex multifactorial mechanisms through which skin and gut microbiota can affect the development of melanoma including microbial metabolites, intra-tumor microbes, UV light, and the immune system. In addition, we will discuss the pre-clinical and clinical studies that have demonstrated the influence of different microbial profiles on response to immunotherapy. Additionally, we will explore the role of microbiota in the development of immune-mediated adverse events.

Value of chemotherapy post immunotherapy in stage IV non-small cell lung cancer (NSCLC)

BACKGROUND

Lung cancer is the number one cause of mortality among all types of cancer worldwide. Its treatment landscape has shifted from the classic chemotherapy alone to newer regimens based on the discovery of new immunotherapy and targeted therapy drugs. However, chemotherapy is still an option for treatment of advanced non-small cell lung cancer (NSCLC) after progression on immunotherapy alone or in combination with first-line chemotherapy.

METHODS

This is a retrospective study based on chart review of patients diagnosed with advanced NSCLC cases who received Docetaxel as second or third line after being treated by immunotherapy and/or chemotherapy in previous lines. The data was collected from the medical records of physicians' clinics in three different hospital centers in Lebanon over the period of 5 years from July 2015 until December 2020. February 2021 was data analysis cut off time. The main aim was to assess the role of Docetaxel post-chemoimmunotherapy for patients with diagnosed NSCLC.

RESULTS

A total of 21 patients were included in this study. The majority of our patients were males (81%). As for histologic type, most patients had non-squamous lung cancer (67%) as compared to 33% who had squamous lung cancer. Overall, our study reported a 24% response rate to Docetaxel including stable disease and partial response and a median progression free survival (PFS) of 3 months. The mean time interval elapsed from diagnosis to the initiation of Docetaxel was 11.5 months.

CONCLUSION

New therapeutic options should be validated for the treatment of NSCLC in the second and subsequent lines of therapy considering the poor prognosis of this disease. The chemotherapy in second and third line may keep an important role in the treatment after progression on newer agents, but it needs more evidence in prospective studies including a larger number of patients.

Metabolic syndrome is independently associated with improved overall survival to first-line therapy with immune checkpoint inhibitors in non-small cell lung cancer

Background

Many co-existing medical conditions may affect the outcome in patients treated with immune checkpoint inhibitors for advanced cancer. There is currently not any information on whether metabolic syndrome (MetS) impacts the clinical outcome in patients treated with immune checkpoint inhibitors (ICIs) for advanced non-small cell line cancer (NSCLC).

Methods

We carried out a single-center retrospective cohort study to determine the effects of MetS on first-line ICI therapy in patients with NSCLC.

Results

One hundred and eighteen consecutive adult patients who received first-line therapy with ICIs and had adequate medical record information for the determination of MetS status and clinical outcomes were included in the study. Twenty-one patients had MetS and 97 did not. There was no significant difference between the two groups in age, gender, smoking history, ECOG performance status, tumor histologic types, pre-therapy use of broad-spectrum antimicrobials, PD-L1 expression, pre-treatment neutrophil:lymphocyte ratio, or proportions of patients who received ICI monotherapy or chemoimmunotherapy. With a median follow-up of 9 months (range 0.5-67), MetS patients enjoyed significantly longer overall survival (HR 0.54, 95% CI: 0.31-0.92) (p = 0.02) but not progression-free survival. The improved outcome was only observed in patients who received ICI monotherapy and not chemoimmunotherapy. MetS predicted for higher probability of survival at 6 months (p = 0.043) and 12 months (p = 0.008). Multivariate analysis indicated that, in addition to the known adverse effects of use of broad-spectrum antimicrobials and the beneficial effects of PD-L1 (Programmed cell death-ligand 1) expression, MetS was independently associated with improved overall survival but not progression-free survival.

Conclusions

Our results suggest that MetS is an independent predictor of treatment outcome in patients who received first-line ICI monotherapy for NSCLC.

Liquid biopsies and minimal residual disease in lymphoid malignancies

Minimal residual disease (MRD) assessment using peripheral blood instead of bone marrow aspirate/biopsy specimen or the biopsy of the cancerous infiltrated by lymphoid malignancies is an emerging technique with enormous interest of research and technological innovation at the current time. In some lymphoid malignancies (particularly ALL), Studies have shown that MRD monitoring of the peripheral blood may be an adequate alternative to frequent BM aspirations. However, additional studies investigating the biology of liquid biopsies in ALL and its potential as an MRD marker in larger patient cohorts in treatment protocols are warranted. Despite the promising data, there are still limitations in liquid biopsies in lymphoid malignancies, such as standardization of the sample collection and processing, determination of timing and duration for liquid biopsy analysis, and definition of the biological characteristics and specificity of the techniques evaluated such as flow cytometry, molecular techniques, and next generation sequencies. The use of liquid biopsy for detection of minimal residual disease in T-cell lymphoma is still experimental but it has made significant progress in multiple myeloma for example. Recent attempt to use artificial intelligence may help simplify the algorithm for testing and may help avoid inter-observer variation and operator dependency in these highly technically demanding testing process.

Systemic AL amyloidosis: current approach and future direction

Systemic Light chain (AL) amyloidosis is a monoclonal plasma cell proliferative disorder characterized by deposition of amyloidogenic monoclonal light chain fragments causing organ dysfunction. It is a fatal disease and if not diagnosed and treated early can lead to organ failure and potentially death. The renal system along with the cardiovascular system are the most common organs involved but other organs such as gut and liver can be involved as well. The initial evaluation of patients requires confirming the diagnosis with tissue biopsy and staining with Congo red followed by confirmatory typing with mass spectrometry of the Congo red positive tissue. Then establishing the extent of the organs involvement by various staging and biomarkers testing. The treatment options and the tolerability of therapy depend on the disease staging, frailty, and co-morbidities. The autologous hematopoietic cell transplantation (HCT) after high dose melphalan therapy is an effective strategy which is usually done after initial bortezomib induction therapy. Unfortunately, most systemic AL amyloidosis patients are not candidate for HCT due to frailty, old age, multi-organ involvement, renal and heart failure at the time of diagnosis. While it is widely accepted that the patients need to be treated until they achieve complete hematologic response, the maintenance therapy after HCT is not well established in AL amyloidosis. In this review, we report the literature on the latest treatment updates of AL amyloidosis and the ongoing clinical trials highlighting the future treatments.

Genomic landscape of metastatic breast cancer (MBC) patients with methylthioadenosine phosphorylase (MTAP) loss

INTRODUCTION

Homozygous deletion of MTAP upregulates de novo synthesis of purine (DNSP) and increases the proliferation of neoplastic cells. This increases the sensitivity of breast cancer cells to DNSP inhibitors such as methotrexate, L-alanosine and pemetrexed.

MATERIALS AND METHODS

7,301 cases of MBC underwent hybrid-capture based comprehensive genomic profiling (CGP). Tumor mutational burden (TMB) was determined on up to 1.1 Mb of sequenced DNA and microsatellite instability (MSI) was determined on 114 loci. Tumor cell PD-L1 expression was determined by IHC (Dako 22C3).

RESULTS

208 (2.84%) of MBC featured MTAP loss. MTAP loss patients were younger (p = 0.002) and were more frequently ER- (30% vs. 50%; p < 0.0001), triple negative (TNBC) (47% vs. 27%; p < 0.0001) and less frequently HER2+ (2% vs. 8%; p = 0.0001) than MTAP intact MBC. Lobular histology and CDH1 mutations were more frequent in MTAP intact (14%) than MTAP loss MBC (p < 0.0001). CDKN2A (100%) and CDKN2B (97%) loss (9p21 co-deletion) were significantly associated with MTAP loss (p < 0.0001). Likely associated with the increased TNBC cases, BRCA1 mutation was also more frequent in MTAP loss MBC (10% vs. 4%; p < 0.0001). As for immune checkpoint inhibitors biomarkers, higher TMB >20 mut/Mb levels in the MTAP intact MBC (p < 0.0001) and higher PD-L1 low expression (1-49% TPS) in the MTAP loss MTAP (p = 0.002) were observed.

CONCLUSIONS

MTAP loss in MBC has distinct clinical features with genomic alterations (GA) affecting both targeted and immunotherapies. Further efforts are necessary to identify alternative means of targeting PRMT5 and MTA2 in MTAP-ve cancers to benefit from the high-MTA environment of MTAP-deficient cancers.

Characterization and susceptibility of non-albicans Candida isolated from various clinical specimens in Lebanese hospitals

Background

Invasive fungal infections have presented a challenge in treatment. In the past, it was known that the frontrunner in such infections is Candida albicans with little emphasis placed on non-albicans Candida species (NAC). Studies worldwide have shown a rise in fungal infections attributed to non-albicans Candida species. The aim of this study is to describe the epidemiology of NAC infections along with an overview of resistance in Lebanese hospitals.

Methods

This is a two-year observational multi-central descriptive study. Between September 2016 and May of 2018, a total of 1000 isolates were collected from 10 different hospitals distributed all over the country. For the culture, Sabouraud Dextrose Agar was used. Antifungal Susceptibility was evaluated by determining the Minimum Inhibitory Concentration (MIC) in broth (microdilution) of the different antifungal treatments.

Results

Out of the 1000 collected isolates, Candida glabrata, being the most isolated species (40.8%), followed by Candida tropicalis: 231(23.1%), Candida parapsilosis: 103(10.3%), and other NAC species at lower percentage. Most of these isolates (88.67%) were susceptible to posaconazole, 98.22% were susceptible to micafungin, and 10% were susceptible to caspofungin.

Conclusion

The change of etiology of fungal infections involving a significant increase in NAC cases is alarming due to the different antifungal susceptibility patterns and the lack of local guidelines to guide the treatment. In this context, proper identification of such organisms is of utmost importance. The data presented here can help in establishing guidelines for the treatment of candida infections to decrease morbidity and mortality. Future surveillance data are needed.

Social disparities in pain management provision in stage IV lung cancer: A national registry analysis

A strong association exists between pain and lung cancer (LC). Focusing on the disparities in pain referral in LC patients, we are aiming to characterize the prevalence and patterns of referrals to pain management (PM) in Stage IV non-small-cell LC (NSLC) and small-cell LC (SCLC). We sampled the National Cancer Database for de novo stage IV LC (2004-2016). We analyzed trends of pain referral using the Cochran-Armitage test. Chi-squared statistics were used to identify the sociodemographic and clinico-pathologic determinants of referral to PM, and significant variables (P < .05) were included in one multivariable regression model predicting the likelihood of pain referral. A total N = 17,620 (3.1%) of NSLC and N = 4305 (2.9%) SCLC patients were referred to PM. A significant increase in referrals was observed between 2004 and 2016 (NSLC: 1.7%-4.1%, P < .001; SCLC: 1.6%-4.2%, P < .001). Patient and disease factors played a significant role in likelihood of referral in both groups. Demographic factors such as gender, age, and facility type played a role in the likelihood of pain referrals, highlighting the gap and need for multidisciplinary PM in patients with LC. Despite an increase in the proportion of referrals to PM issued for terminal stage LC, the overall proportion remains low. To ensure better of quality of life for patients, oncologists need to be made aware of existent disparities and implicit biases.

Radiation Recall Dermatitis Following Treatment With Pembrolizumab: A Case Report and Review of the Literature

Radiation recall dermatitis is an inflammatory reaction of the skin that may infrequently occur in areas of the skin that have been previously treated with radiation therapy. This is thought to be due to a triggering agent administered after radiation therapy which leads to an acute inflammatory reaction, manifesting as a skin rash. We present the case of a 58-year-old male with recurrent invasive squamous cell carcinoma of the tongue, previously treated with chemotherapy and radiation therapy, who presented with progression of his disease. He was treated with pembrolizumab and subsequently developed a new-onset facial rash over the previously treated radiation field. The distribution of the rash was suggestive of radiation recall dermatitis. A biopsy showed dermal necrosis without evidence of dermatitis, vasculitis, or infectious process. This case highlights the incidence of a rare complication of immune checkpoint inhibitor therapy and emphasizes the need for careful monitoring for radiation recall dermatitis.

Liquid biopsies and minimal residual disease in myeloid malignancies

Minimal residual disease (MRD) assessment through blood component sampling by liquid biopsies (LBs) is increasingly being investigated in myeloid malignancies. Blood components then undergo molecular analysis by flow cytometry or sequencing techniques and can be used as a powerful tool for prognostic and predictive purposes in myeloid malignancies. There is evidence and more is evolving about the quantification and identification of cell-based and gene-based biomarkers in myeloid malignancies to monitor treatment response. MRD based acute myeloid leukemia protocol and clinical trials are currently incorporating LB testing and preliminary results are encouraging for potential widespread use in clinic in the near future. MRD monitoring using LBs are not standard in myelodysplastic syndrome (MDS) but this is an area of active investigation. In the future, LBs can replace more invasive techniques such as bone marrow biopsies. However, the routine clinical application of these markers continues to be an issue due to lack of standardization and limited number of studies investigating their specificities. Integrating artificial intelligence (AI) could help simplify the complex interpretation of molecular testing and reduce errors related to operator dependency. Though the field is rapidly evolving, the applicability of MRD testing using LB is mostly limited to research setting at this time due to the need for validation, regulatory approval, payer coverage, and cost issues. This review focuses on the types of biomarkers, most recent research exploring MRD and LB in myeloid malignancies, ongoing clinical trials, and the future of LB in the setting of AI.

Insights of Medical Students and Graduates Toward Electronic Learning During the COVID-19 Pandemic in Lebanon: A National Cross-Sectional Study

OBJECTIVE

This study examines the perceptions of Lebanese medical students and graduates regarding the switch to electronic learning (e-learning) and measures their psychological distress amid the COVID-19 pandemic, compounded by an unprecedented financial collapse and the August 4 Beirut blast.

METHODS

This is a national cross-sectional descriptive study, consisting of a 48-item questionnaire, diffused online to Lebanese medical students between February 8 and 21, 2021. The survey divided into 5 sections assesses for (1) Sociodemographic information, (2) implemented changes in medical education delivery precipitated by the pandemic, (3) students' perceptions regarding the effectiveness, advantages, and barriers of e-learning, and (4) role of e-learning in clinical training. Finally, students' psychological distress was measured, using the Kessler 10-item distress scale (K10). Descriptive analyses were performed using Stata version 13 and Excel.

RESULTS

1060 responses were recorded (27% response rate) across all Lebanese medical schools. Although 71.6% of participants found e-learning to be stimulating, half of the participants thought it was not equally effective to face-to-face learning. Around 73.1% of students felt they were not able to learn hands-on clinical skills. Lebanese students identified cost savings (food, transportation etc) and poor internet connectivity are the most common advantage and barrier, respectively; 77.8% of participants showed high/very high levels of distress (K10 score ≥22).

CONCLUSIONS

Ensuring accessibility and availability of resources such as electricity and internet is of utmost priority. Lebanese medical schools need to incorporate clinical training experiences to their virtual platforms to maintain the quality of medical education to their students. A particular attention to students' mental health is warranted, by increasing awareness and access to mental health services.

The Gut Microbiome and Alzheimer's Disease: A Growing Relationship

Evidence that the gut microbiota plays a key role in the pathogenesis of Alzheimer's disease is already un-ravelling. The microbiota-gut-brain axis is a bidirectional communication system that is not fully understood but includes neural, immune, endocrine, and metabolic pathways. The progression of Alzheimer's disease is supported by mechanisms related to the imbalance in the gut microbiota and the development of amyloid plaques in the brain, which are at the origin of Alzheimer's disease. Alterations in the composition of the gut microbiome led to dysregulation in the pathways governing this system. This leads to neurodegeneration through neuroinflammation and neurotransmitter dysregulation. Neurodegeneration and disruption of the blood-brain barrier are frontiers at the origin of Alzheimer's disease. Furthermore, bacteria populating the gut microbiota can secrete large amounts of amyloid proteins and lipopolysaccharides, which modulate signaling pathways and alter the production of proinflammatory cytokines associated with the pathogenesis of Alz-heimer's disease. Importantly, through molecular mimicry, bacterial amyloids may elicit cross-seeding of misfolding and induce microglial priming at different levels of the brain-gut-microbiota axis. The potential mechanisms of amyloid spreading include neuron-to-neuron or distal neuron spreading, direct blood-brain barrier crossing, or via other cells such as astrocytes, fibroblasts, microglia, and immune system cells. Gut microbiota metabolites, including short-chain fatty acids, pro-inflammatory factors, and neurotransmitters may also affect AD pathogenesis and associated cognitive decline. The purpose of this review is to summarize and discuss the current findings that may elucidate the role of gut microbiota in the development of Alzheimer's disease. Understanding the underlying mechanisms may provide new insights into novel therapeutic strategies for Alzheimer's disease, such as probiotics and targeted oligosaccharides.

Efficacy of chemotherapy in patients with HR+/HER2-Invasive lobular breast cancer

INTRODUCTION

Invasive Lobular Breast Cancer (ILC) harbors unique clinicopathologic features. Data on optimal treatment modalities focusing on ILC remain scarce. We aim to investigate the benefit of chemotherapy in early-stage hormone receptor-positive (HR+) and human epidermal growth factor receptor-2 negative (HER2-) ILC.

METHODS

Female patients with early HR+/HER2- ILC (stages I-III) who underwent surgery were selected from the National Cancer Database (2010-2016) and grouped into four treatment cohorts: surgery only(S), chemotherapy alone (CT), endocrine therapy alone (ET), and combined chemotherapy followed by endocrine therapy (CET). Descriptive and bi-variate statistics summarized baseline characteristics and compared them across cohorts. A secondary analysis accounting for OncotypeDX (ODX) information was performed, stratifying for low (<26) and high (≥26) ODX. Kaplan-Meier (KM) and Cox proportional hazard models evaluated the relationship between treatment modality and overall survival (OS), stratifying for ODX scoring.

RESULTS

N = 15,271 patients were included. The CET cohort (29.8%) was more likely to be younger and have no co-morbidities, advanced tumor stage or high ODX score (≥26). No significant difference in OS comparing ET to CET (HR:1.08, 95%CI:0.93-1.26, p = 0.31) was observed, adjusting for confounders. N = 5,561 patients had ODX results available. No significant difference in 5-year OS was observed comparing the ET to CET cohorts, both in patients an ODX score <26 (HR:1.10; 95%CI:0.69-1.76, p = 0.69) and ODX score ≥26 (HR:1.18; 95%CI:0.51-2.75, p = 0.69).

CONCLUSION

Chemotherapy demonstrated no added survival benefit in HR+/HER2- ILC, even in tumors with ODX ≥26. Prospective trials identifying potential subgroups of patients with ILC who could benefit from chemotherapy are needed.

Recent Advances in the Treatment and Supportive Care of POEMS Syndrome

POEMS is a rare clonal plasma cell disorder characterized by multi-systemic features that include demyelinating peripheral neuropathy, organomegaly, endocrinopathy, presence of monoclonal proteins (M-protein), and skin changes. Even though the pathophysiology is poorly understood, recent studies suggest that both clonal and polyclonal plasmacytosis leading to the production of pro-inflammatory cytokines and angiogenic mediators play the central role. These mediators including vascular endothelial growth factor (VEGF) are the driving forces of the syndrome. The diagnosis of POEMS is not always straight forward and often the diagnosis is delayed. It is based on fulfilling mandatory criteria of polyradiculoneuropathy and monoclonal protein and the presence of one major criterion (Castleman disease, sclerotic bone lesions, or elevated VEGF), and at least one minor criterion. Due to the presence of neuropathy, it can be confused with chronic inflammatory demyelinating polyradiculopathy (CIDP), and if thrombocytosis and splenomegaly are present, it can be confused with myeloproliferative neoplasms. Due to the rarity of the syndrome, clear guidelines for treatment are still lacking. Immediate treatment targeting the underlying plasma cell proliferation results in a dramatic response in most patients. The key is early diagnosis and immediate anti-plasma cell directed therapy for the best clinical outcomes. For patients with disseminated disease as defined by bone marrow involvement or more than three osteosclerotic bone lesions, high-dose chemotherapy with autologous hematopoietic stem cell transplant (ASCT) yields durable responses and is the preferred treatment in eligible patients. For patients with localized bony disease, radiotherapy has proven to be very effective. Lenalidomide and dexamethasone is a proven therapy in patients ineligible for ASCT. In this review article, we tackle the diagnostic approach and discuss the latest treatment modalities of this rare debilitating disease.

Latest updates on cellular and molecular biomarkers of gliomas

Gliomas are the most common central nervous system malignancies, compromising almost 80% of all brain tumors and is associated with significant mortality. The classification of gliomas has shifted from basic histological perspective to one that is based on molecular biomarkers. Treatment of this type of tumors consists currently of surgery, chemotherapy and radiation therapy. During the past years, there was a limited development of effective glioma diagnostics and therapeutics due to multiple factors including the presence of blood-brain barrier and the heterogeneity of this type of tumors. Currently, it is necessary to highlight the advantage of molecular diagnosis of gliomas to develop patient targeted therapies based on multiple oncogenic pathway. In this review, we will evaluate the development of cellular and molecular biomarkers for the diagnosis of gliomas and the impact of these diagnostic tools for better tailored and targeted therapies.

The Lung Microbiota and Lung Cancer: A Growing Relationship

Simple Summary

In the past few years, the microbiota has emerged as a major player in cancer management. The efficacy of chemotherapy or immunotherapy may be influenced by the concomitant use of antibiotics before, during, or shortly after treatment with immune checkpoint inhibitors. Despite this, the mechanism linking the microbiota, host immunity, and malignancies are not clear, and the role of microbiota manipulation and analyses in cancer management is underway. In this manuscript, we discuss the role of the microbiota in the initiation, progression, and treatment outcomes of lung cancer.

Abstract

The lung is home to a dynamic microbial population crucial to modulating immune balance. Interest in the role of the lung microbiota in disease pathogenesis and treatment has exponentially increased. In lung cancer, early studies suggested an important role of dysbiosis in tumor initiation and progression. These results have helped accelerate research into the lung microbiota as a potential diagnostic marker and therapeutic target. Microbiota signatures could represent diagnostic biomarkers of early-stage disease. Lung microbiota research is in its infancy with a limited number of studies and only single-center studies with a significant methodological variation. Large, multicenter longitudinal studies are needed to establish the clinical potential of this exciting field.

Single Cell RNA Sequencing: A New Frontier in Pancreatic Ductal Adenocarcinoma

Simple Summary

Pancreatic cancer has a very low survival rate for several reasons. One of those is primarily due to the difficulty in diagnosing it at an early stage. For this reason, it is important to refine our understanding of this disease to guide the development of new diagnostic and therapeutic modalities to combat this fatal illness. Here we attempt to provide a review of current progress in utilizing single-cell RNA sequencing (scRNA-seq) techniques in the molecular profiling of pancreatic ductal adenocarcinoma.

Abstract

Pancreatic ductal adenocarcinoma is a malignancy with a high mortality rate. It exhibits significant heterogeneity in metabolic pathways which are associated with its progression. In this review, we discuss the role of single cell RNA sequencing in unraveling the metabolic and clinical features of these highly malignant tumors.

COVID-19 and lung cancer: update on the latest screening, diagnosis, management and challenges

Lung cancer, considered one of the most common causes of cancer deaths worldwide, is a complex disease with its own challenges. The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), compounded these challenges and forced the medical healthcare system to alter its approach to lung cancer. This narrative review aims to identify the effect of the COVID-19 pandemic on lung cancer screening, diagnosis and management. During this public health crisis, various medical societies have worked on developing guidelines to protect patients with lung cancer from the deleterious effects of SARS-CoV-2 infection, as well as from the complications imposed by treatment delays. The different therapeutic approaches, such as surgery, radiation oncology and immune checkpoint inhibitor therapy, along with the latest international recommendations, will be discussed. Protecting patients with lung cancer from COVID-19 complications, while avoiding barriers in treatment delays, has brought unique challenges to healthcare facilities. Prompt modifications to guidelines, and constant evaluation of their efficacy, are thus needed.

Management of HR+/HER2+ lobular breast cancer and trends do not mirror better outcomes

Purpose

Treatment protocols for invasive lobular breast cancer (ILC) have largely followed those for invasive ductal breast cancer. This study compares treatment outcomes of endocrine therapy versus combined chemo-endocrine therapy in hormone-receptor-positive (HR+), HER2-positive (HER2+) ILC tumors in a large national registry.

Methods

We sampled the National Cancer Database (2010–2016) for female patients with stages I-III, HR+/HER2+ ILC who underwent surgery. Cochran-Armitage trend test examined trends of treatment regimen administration: Surgery only (S), chemotherapy (C), endocrine therapy (ET), and combined chemo-endocrine therapy (CET), with or without anti-HER2 therapy. Cox proportional hazard model were used to compare overall survival (OS) across ET and CET cohorts, stratifying for anti-HER2 therapy, before and after propensity score match of cohorts (2013–2016). Kaplan-Meier (KM) survival curves were also produced.

Results

N=11,421 were included. 58.7% of patients received Anti-Her2 therapy after 2013. CET conferred better OS over ET in the unmatched (adjusted-5-year-OS: 92.5% vs. 81.1%, p<0.001) and PS-matched (90.4% vs. 84.5%, p=0.001) samples. ET caused lower OS in patients who received Anti-Her2 therapy (HR: 2.56, 95% CI: 1.60–4.12, p<0.001) and patients who did not (HR: 1.84, 95% CI: 1.21–2.78, p=0.004), as compared to CET on multivariable analysis. KM modeling showed highest OS in the CET cohort who received Anti-Her2 (93.0%), followed by the CET cohort who did not receive Anti-Her2 (90.2%) (p=0.06).

Conclusion

Chemotherapy followed by endocrine therapy and Anti-Her2 therapy was shown to be the most effective treatment modality in HR+/HER2+ ILC, contrasting previous data on the inconclusive benefit of chemotherapy in patients with ILC.

•

Less chemotherapy (CT) is used in favor of endocrine therapy (ET) alone for HR+/HER2+ ILBC at the expense of efficacy.

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CT followed by ET remains an effective treatment in HR+/HER2+ ILBC, specifically for larger and locally advanced tumors.

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Research investigating subgroups of lobular BC who would benefit from CT de-escalation, or ET alone without CT is needed.

The Urogenital System’s Role in Diseases: A Synopsis

Simple Summary

The urinary tract microbiome has come under a lot of scrutiny, and this has led to the rejection of the pre-established concept of sterility in the urinary bladder. Microbial communities in the urinary tract have been implicated in the maintenance of health. Thus, alterations in their composition have also been associated with different urinary pathologies, such as urinary tract infections. For that reason, tackling the urinary microbiome of healthy individuals, as well as its involvement in disease through the proliferation of opportunistic pathogens, could open a potential field of study, leading to new insights into prevention, diagnosis, and treatment strategies for different diseases.

Abstract

The human microbiota contains ten times more microbial cells than human cells contained by the human body, constituting a larger genetic material than the human genome itself. Emerging studies have shown that these microorganisms represent a critical determinant in human health and disease, and the use of probiotic products as potential therapeutic interventions to modulate homeostasis and treat disease is being explored. The gut is a niche for the largest proportion of the human microbiota with myriad studies suggesting a strong link between the gut microbiota composition and disease development throughout the body. More specifically, there is mounting evidence on the relevance of gut microbiota dysbiosis in the development of urinary tract disease including urinary tract infections (UTIs), chronic kidney disease, and kidney stones. Fewer emerging reports, however, are suggesting that the urinary tract, which has long been considered ‘sterile’, also houses its unique microbiota that might have an important role in urologic health and disease. The implications of this new paradigm could potentially change the therapeutic perspective in urological disease.

Carbapenemase Inhibitors: Updates on Developments in 2021

Carbapenem resistance, an emerging global health problem, compromises the treatment of infections caused by nosocomial pathogens. Preclinical and clinical trials demonstrate that a new generation of carbapenemases inhibitors, together with the recently approved avibactam, relebactam and vaborbactam, would address this resistance. Our review summarizes the latest developments related to carbapenemase inhibitors synthesized to date, as well as their spectrum of activity and their current stage of development. A particular focus will be on β-lactam/β-lactamase inhibitor combinations that could potentially be used to treat infections caused by carbapenemase-producer pathogens. These new combinations mark a critical step forward the fight against antimicrobial resistance.

A Survey on the Knowledge, Attitudes, and Practices of Lebanese Physicians Regarding Air Pollution

Introduction: Air pollution imposes a significant burden on public health. It is emerging as a modifiable risk factor for cancer, diabetes, and respiratory and cardiovascular diseases. This study aims to assess the knowledge, attitudes, and practices of Lebanese physicians regarding air pollution. Methods: This observational study uses a descriptive cross-sectional correlational design. The data were collected using a self-administered online survey that was sent to 874 potential respondents who are members of the Lebanese Order of Physicians. Data analysis was done using descriptive statistics and a chi-square test. Results: The results show a deficiency in the knowledge of physicians regarding many sources of air pollution, including dust, the smell of perfume, candles, vacuum cleaners, air fresheners, electronic cigarettes, etc. The majority of physicians agree that air pollution increases the risk of several health problems. Only 38% of physicians routinely ask their patients about exposure to air pollution, and 75% of them believe that they have a role as physicians in reducing air pollution levels. Over half of the sample are confident in counseling their patients on sources of air pollution, and two thirds of them are in support of including assessment of air pollution exposure during regular medical visits. Conclusion: Air pollution levels are progressively increasing over time. Given the health impact of exposure to air pollution, healthcare professionals need to stay up to date on this topic. The results of this study suggest the need for continuing education about air pollution for physicians and developing guidelines for what exactly to ask patients in assessing their exposure.

Landscape of fibroblast growth factor receptor (FGFR) genomic alterations (GA) in urothelial bladder cancer (UBC)

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Background: Urothelial bladder carcinomas (UBC) with genomic alterations (GA) in the Fibroblast Growth Factor Receptor ( FGFR) genes have been postulated to be less responsive to immune checkpoint inhibitors (ICI). Immune microenvironment of these tumors could be altered due to suppression of interferon signaling pathways. Here, we present comprehensive genomic profiling (CGP) of FGFR altered UBC to study the underlying immunogenomic mechanisms of response and resistance. Methods: 4,035 UBC underwent hybrid capture based CGP. Tumor mutational burden (TMB) was determined on up to 1.1 Mbp of sequenced DNA and microsatellite instability (MSI) was determined using 114 loci. Programmed death ligand (PD-L1) expression in tumor cells was assessed by IHC (Dako 22C3). Results: 894 (22%) of UBC featured FGFR GA ( FGFR1 3.7%; FGFR2 1.1%; FGFR3 17.4%). Gender and age distribution was similar in all groups. FGFR3 cases had lower GA/tumor and 14.7% GA were fusions. ERBB2 amplification was significantly higher in FGFR1/2 altered UBC compared with FGFR3 altered UBC. MTOR pathway GA were highest in FGFR3 altered UBC. FGFR3 altered UBC featured significantly higher frequencies of biomarkers predicting resistance to ICI including lower TMB, lower PD-L1 expression and higher frequencies of GA in MDM2. FGFR3 driven UBC also features significantly higher frequencies of CDKN2A/B loss and MTAP loss which have also recently been linked to IO drug resistance. Conclusions: UBC harboring FGFR GA have increased frequency of alterations that have been linked to ICI resistance. Further evaluation of FGFR-based biomarkers in UBC clinical trials focused on the assessment of the patient response to ICI appears warranted. [Table: see text]

Outcome of cancer patients affected by COVID-19 in different settings

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Background: The mortality rate of cancer patients diagnosed with COVID-19 infection has reached 25%. The time from symptom onset to admission to the intensive care unit (ICU) was on average 10 days, with approximately 26% of patients requiring ICU admission. A higher mortality attributed to COVID-19 was seen in older patients, patients with certain cancer types, and patients with a higher Charslon comorbidity score. Moreover, male sex and leukopenia at diagnosis were associated with an increased risk of worse clinical outcomes. Furthermore, a study done at Memorial Sloan Kettering showed that patients with hematological malignancies had a worse prognosis than those with solid tumors. Our aim is to identify the predictive factors for ICU admission in the setting of positive COVID-19 infection in cancer patients. Differences in prognosis were compared between cancer and non-cancer patients admitted to the ICU due to COVID-19 infection. We also compared the overall outcome between patients with solid cancers and hematologic malignancies. Methods: This is a single institution retrospective study based on chart review analysis conducted at the American University of Beirut Medical Center (AUBMC). 248 patients were diagnosed with COVID-19 from 1 January 2020 to 31 December 2021. The patient groups were (1) all cancer patients admitted to the COVID unit, (2) all cancer patients admitted to ICU, and (3) all other patients without cancer admitted to the ICU. The main outcomes were ICU admission and mortality. Results: 173 cancer patients were admitted to our institution for the management of COVID-19 with a mean age of 63 years. 52 patients (30%) required ICU admission and 50 patients (29%) died during hospital stay or 1 month following discharge. The time from symptom onset to ICU admission and death were 12.8 and 35 days, respectively. Patients admitted to the ICU were more likely to have anemia (Hb < 8 g/dL) and thrombocytopenia (< 50,000/mm3) on admission (p = 0.001). Age, male sex and history of smoking, diabetes or cardiopulmonary diseases were not associated with greater risk of ICU admission or death. Among cancer patients, those with uncontrolled disease at the onset of COVID-19 had greater risk of death from COVID-19 (p = 0.001). Cancer type, number of lines of treatment, history of radiation to the chest, recent cytotoxic therapy, and neutropenia were not associated with ICU admission or death from COVID-19. There was no statistical significance in mortality or disease progression between patients with solid or hematologic malignancies. Conclusions: Our data reaffirms previously reported findings of high mortality in cancer patients who contract COVID-19. In particular, patients with anemia, thrombocytopenia, and uncontrolled disease at diagnosis had unfavorable outcomes. Contrary to the literature, age, male sex, cancer type, and neutropenia were not predictive factors for mortality in cancer patients in the setting of COVID-19 infections.

Piperacillin/Tazobactam and Meropenem Use Increases the Risks for Acute Graft Rejection Following First Kidney Transplantation

Many broad-spectrum antibiotics (BSA) alter the intestinal microbiome that regulates adaptive immune responses. We hypothesized that BSA use before and early after kidney transplant may affect acute graft rejection (AGR). We carried out a retrospective cohort study on all patients who underwent kidney transplants in our institution. Patient demographics, clinical data, diagnosis, and treatment history were collected. Antibiotic use within 2 months prior to transplant and during the hospital admissions for transplant, as well as antibiotic types were recorded. A total of 357 consecutive first transplants were included for analysis. Median age was 52 years (range 7–76). A total of 67 patients received living donor and 290 deceased donor kidneys. A total of 19 patients received BSA within two months prior to transplant and 55 patients during the hospital admission for the transplant. With a median follow-up of 1270 days, 38 episodes of biopsy-proven AGR were recorded. There was no difference in the AGR rates during the first year between patients who received BSA and those who did not. However, the use of piperacillin/tazobactam or meropenem (PM) was associated with increased risks for the development of AGR, irrespective of the source of the donor grafts. Time to development of AGR was also shorter. Our data, therefore, suggest that the use of PM BSA prior to and immediately after kidney transplant increases the risks for AGR.

Adhesion molecules in multiple myeloma oncogenesis and targeted therapy

Every day we march closer to finding the cure for multiple myeloma. The myeloma cells inflict their damage through specialized cellular meshwork and cytokines system. Implicit in these interactions are cellular adhesion molecules and their regulators which include but are not limited to integrins and syndecan-1/CD138, immunoglobulin superfamily cell adhesion molecules, such as CD44, cadherins such as N-cadherin, and selectins, such as E-selectin. Several adhesion molecules are respectively involved in myelomagenesis such as in the transition from the precursor disorder monoclonal gammopathy of undetermined significance to indolent asymptomatic multiple myeloma (smoldering myeloma) then to active multiple myeloma or primary plasma cell leukemia, and in the pathological manifestations of multiple myeloma.

Descriptive epidemiology of soft tissue and bone sarcomas in Lebanon

OBJECTIVES

Most epidemiologic studies on soft tissue sarcomas (STS) and bone sarcomas (BS) are performed in western countries, with few in the Middle East and North Africa region. We describe the epidemiology of sarcomas in Lebanon using the medical records database at the American University of Beirut Medical Center (AUBMC).

METHODS

This single-center retrospective cohort study included patients with sarcomas registered in the database between 2015 and 2019. Their charts were reviewed for baseline characteristics, tumor biology and location, treatment modalities, recurrence, metastasis, and death.

RESULTS

The cohort included 234 patients with STS and 99 patients with BS. Most tumors were <10 cm in size. The most common subtypes were liposarcoma for STS and osteosarcoma for BS. The most common location of STS was the thigh. The most frequent sites of STS metastasis were the lungs. Histological subtype, smoking status, and tumor size and grade were significant for progression-free survival (PFS) in patients with STS. By multivariable analysis, smoking was significantly associated with poorer PFS in STS. For BS, only tumor grade was significant for PFS.

CONCLUSION

The epidemiology of sarcomas at AUBMC is similar to that previously reported. Smoking history was associated with poorer survival in patients with STS.

Role of circulating tumor DNA and circulating tumor cells in breast cancer: History and updates

Circulating tumor DNA, cell-free DNA, and circulating tumor cells have been at the epitome of recent research in breast cancer. These forms of liquid biopsies have been used in monitoring disease progression, estimating the risk of relapse, and response to treatment. Much has been done in relation to serial monitoring of circulating tumor DNA in patients with primary breast cancer for detection of occult metastatic disease. Some studies have also explored their use in monitoring treatment response. As the field of liquid biopsies expands, more prospective studies are needed to tailor management in an individualistic approach. In this literature review, the authors explore the multiple uses of circulating tumor DNA and circulating tumor cells in breast cancer.

Triple Negative Breast Cancer: Updates on Classification and Treatment in 2021

Simple Summary

Triple negative breast cancer (TNBC) represents 15 to 20% of all breast cancers in the United States. The main treatment option remains chemotherapy, despite limited efficacy. New biologic and targeted agents are increasingly emerging for the treatment of TNBC. Given the continuous advances in the field of TNBC, this review assesses the latest developments in basic characterization, subtyping, and treatment of TNBC, including novel drug developments with antibody-drug conjugates, immune checkpoint inhibitors, PARP inhibitors, and androgen receptor targeted agents.

Abstract

Breast cancer (BC) is the most common malignancy affecting women. It is a highly heterogeneous disease broadly defined by the differential expression of cell surface receptors. In the United States, triple negative breast cancer (TNBC) represents 15 to 20% of all BC. When compared with other subtypes of BC, TNBC tends to present in younger women, and has a higher mortality rate of 40% in advanced stages within the first 5 years after diagnosis. TNBC has historically had limited treatment options when compared to other types of BC. The mainstay of treatment for TNBC remains cytotoxic chemotherapy despite the emergence of new biologic and targeted agents. Defining the specific tumor molecular profile including PDL-1 and androgen receptor testing is expanding treatment options in the clinical setting. Identifying more targetable, novel biomarkers that may better define therapeutic targets or prognostic markers is currently underway. TNBC nomenclature is expected to be updated in favor of other nomenclature which would help direct therapy, and further redefine TNBC’s heterogeneity. Given the continuous advances in the field of TNBC, this review assesses the latest developments in basic characterization, subtyping, and treatment of TNBC, including novel drug developments with antibody-drug conjugates, immune checkpoint inhibitors, PARP inhibitors and androgen receptor targeted agents. Future trials are necessary in the face of these innovations to further support the use of new therapies in TNBC and the detection of the appropriate biomarkers.

Abstract P2-07-07: Does OncotypeDX have predictive value in HER2+ breast cancer?

Background: The 21-gene OncotypeDX (ODX) assay has been validated as a predictive biomarker in early-stage hormone receptor positive (HR+) and HER2- breast cancer. This multigene panel identifies patients with a high risk of recurrence who would benefit systemic treatment involving both chemotherapy and endocrine therapy, versus endocrine therapy alone. ODX is not indicated in HER2 + breast cancer. Not all patients with HER2+ breast cancer are candidates for anti-HER2 treatments due to the potential for cardiotoxicity. We were interested to assess the value of ODX in predicting benefit of anti-HER2 treatment in HR+ and HER2+ breast cancer. Methods: We used the National Cancer Database to identify patients with early-stage (AJCC clinical staging I-II), HR+/HER2+ breast cancer who happen to have received multigene testing with ODX. We described this cohort using univariate descriptive statistics. We then explored the predictive value of this biomarker by constructing two Kaplan-Meier models for overall survival (OS) with log-rank testing. The first model generates OS curves associated with different approaches to systemic treatment (a. endocrine therapy alone, versus b. endocrine therapy + anti-HER2 targeted treatment, versus c. endocrine therapy + chemotherapy, versus d. endocrine therapy + anti-HER2 targeted treatment + chemotherapy) in patients with a recurrence score (RS) &lt; 26. The second model explores for differences in these systemic therapy approaches for those with a RS ≥ 26. Results: N=107,132 patients with early-stage, HR+/HER2+ breast cancer were included in this analysis. ODX testing was performed in n=5,280 (4.93%). The age distribution of this cohort was as follows: n=1,120 (21.2%) &lt; 50 years, n=3,195 (60.5%) between 50-70 years, and n=965 (18.3%) were &gt;70 years. The majority were White (84.9%), 9.6% were Black, and 3.3% were Asian. N=701 patients (13.3%) had a RS &lt; 26, while n=4,353 (82.4%) had a RS &gt;=26. The first Kaplan-Meier survival model indicated no significant difference in OS (p=0.445) between patients receiving different systemic treatment regimens when patients had a low risk of recurrence. However, the second Kaplan-Meier model indicates that when the ODX RS was ≥ 26, there was a statistically-significant difference in OS between systemic treatment regimens (p&lt;0.001). 5-year OS was highest (97.4%) for patients receiving triple therapy (anti-HER2 + chemotherapy + endocrine therapy), followed by those receiving dual therapy with endocrine + anti-HER2 (96.7%), and endocrine + chemotherapy (94.9%). Patients receiving endocrine therapy alone exhibited the lowest 5-year OS (88.5%). Conclusion: Results from this large national cancer registry suggest that multi-gene testing with ODX may have predictive value in treatment selection of patients with early-stage, HR+/HER2+ breast cancer. Prospective trials are warranted to identify subgroups of patients with HR+/HER2+ breast cancer who can be spared anti-HER2 treatments and cytotoxic chemotherapy.

Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Hong Liang, Zeina Nahleh. Does OncotypeDX have predictive value in HER2+ breast cancer? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-07-07.

Abstract P4-05-10: Composite score combining multi-gene testing with liquid biopsy may have stronger prognostic value in HR+/HER2- breast cancer

Background: For patients with early-stage, hormone receptor-positive (HR+) and HER2-negative breast cancer, multigene testing (MGT) is commonly used to personalize treatment. Published data suggests that the 70-gene MammaPrint (MP) assay, while used less commonly, may be superior to the 21-gene OncotypeDX panel at identifying high-risk patients requiring chemotherapy adjunct to endocrine therapy, versus endocrine therapy alone. We previously showed that the presence of circulating tumor cells (CTCs) has prognostic and predictive value in breast cancer. We assess the prognostic value of composite scoring combining liquid biopsy data with MGT. Methods: This retrospective analysis of the National Cancer Database explores the prognostic value of ODX, MP and liquid biopsy identifying CTCs in patients diagnosed between 2004-2017 with early-stage (AJCC clinical stage I-II), HR+/HER- breast cancer. We examined the prognostic value of the following models: 1) ODX alone, 2) MP alone, and 3) ODX-liquid biopsy composite score. The ODX-liquid biopsy composite score was created to be a binary risk stratification as follows: when circulating tumor cells were present, intermediate-risk as per ODX was upstaged to high-risk, but when absent, intermediate-risk was down-staged to low-risk. We compared the effect size of hazard ratios generated by each model’s inclusion in Cox regressions for overall survival that controlled for age and race. We also evaluated the prognostic value of each model through generated Harrell’s C-indices (i.e. area under ROC curve), with a C-index closer to 1 indicating superiority of a model in differentiating high- from low-risk groups. Results: Among early-stage, HR+/HER2- patients (n=841,716), n=271,416 (32.2%) had documented ODX data, n=12,417 (1.5%) had MP data, and n=1,141 (0.14%) had both ODX and CTC data. Based on liquid biopsy results, n=63 patients were upstaged from intermediate- to high-risk in the partial composite ODX-CTC model (20.5% of all intermediate-risk), while the rest (79.5%) were down-staged. A comparison of effect sizes for HRs corroborates preliminary data in the literature that MP alone (HR 2.49, 95% CI 1.94-3.19) may be superior to ODX alone (HR 2.23, 95% CI 2.07-2.39) at prognosticating overall survival. Additionally, we show that a binary composite score of ODX with liquid biopsy may better identify patients with a higher risk of mortality (HR 3.46, 95% CI 1.63-7.31). Comparison of C-indices was not possible for MP scoring or ODX-liquid biopsy scoring, likely due to an inadequate sample size leading to non-significance. Conclusion: Composite scoring based on ODX and liquid biopsy using CTCs may be superior to ODX/MP alone to differentiate high-risk from low-risk prognosis in patients with early-stage, HR+/HER2- BC. If confirmed in larger studies, this composite scoring would be useful in practice to more accurately identify a higher risk patient population to target for additional treatment and close monitoring.

Table 1. Summary of prognostic parameters (HR and C-index) of 3 scoring systems.Prognostic ModelCOX RegressionROC AnalysisHR* (95% CI)C-index (95% CI)p-value1. ODX scoring alone (n=182,861)2.23 (2.07-2.39)0.566 (0.558-0.573)&lt;0.0012. MP scoring alone (n=8,643)2.49 (1.94-3.19)0.527 (0.492-0.562)0.1213. ODX-liquid biopsy composite scoring (n=685) 3.46 (1.63-7.31)0.497 (0.391-0.602)0.952*HRs comparing high-risk to low-risk stratifications, calculated from COX regression for overall survival after controlling for age (5-70) and race (White).

Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Hong Liang, Zeina Nahleh. Composite score combining multi-gene testing with liquid biopsy may have stronger prognostic value in HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-05-10.

Abstract PD14-06: Does chemotherapy benefit patients with HR+/HER2- invasive lobular breast cancer?

Introduction Invasive lobular breast cancer (ILBC) is the second most common subtype of breast cancer. More evidence is emerging on the unique clinical features of ILBC. However, most systemic therapy guidelines for ILBC are derived from clinical trials with no specific focus on ILBC. Also, the benefit of chemotherapy for the treatment ILBC has been questioned. Using a large national registry, we aimed at comparing outcomes of various systemic therapy regimens in hormone receptor-positive (HR+) and HER2- ILBC. Methods We performed a year-stratified simple random sampling method to select 10% of ER+ or PR+ (HR+) and HER2- female patients with ILBC with AJCC stages I-III who underwent surgery from the National Cancer Database (NCDB) (2010-2017). Patients were grouped into four treatment cohorts: surgery only (S), chemotherapy alone (CT), endocrine therapy alone (ET), combined chemotherapy followed by endocrine therapy (CET). Overall survival (OS) among groups was first examined using the Kaplan-Meier method and Cox proportional hazard modeling. Focusing on ET and CET, propensity score (PS) match in logistic regression was performed to reduce selection biases due to demographical and clinical characteristics. OS between PS matched ET and CET pairs were evaluated again using the same methods. OS differences between ET and CET by lobular histology group and by disease stage were also examined. Results Approximately 90% of ILBC were HR+ and HER2+. N=17,789 patients were included in this analysis: 59.7% received ET, 26.2% CET, 2.3% CT and 11.9% S. 5-years OS was significantly better for patients who received ET (90.7%) or CET (90.4%) as compared to CT (79.4%) or S only (79.7%) (p&lt;.001). Of interest, after adjusting for other demographic and clinical characteristics, 5-years OS was similar for both ET and CET (p=.064). Increased ET administration (52.6% to 67.4%, p for trend &lt;.001) and decreased CET (30.4% to 20.2%, p for trend &lt;0.001) were observed from 2010 to 2017. Among n=15,273 patients who underwent ET (n=10,616; 69.5%) or CET (n=4,657; 30.5%), both groups had similar histology findings (45.5% vs 47.7% lobular histology mixed with other features). However, significant demographic and clinical characteristics differences were identified between both cohorts. Patients in the CET group were younger (mean age 56.9±10.5 vs. 65.5±11.6) (p&lt;.001), had a higher stage at diagnosis (34.8% stage III vs. 4.2%), more positive regional LN (67.5% vs. 13.7%), and received more radiation therapy (74.1% vs. 58.5%) as compared to those in the ET group. 5-years OS remained similar between ET and CET when adjusting for age, stage, LN involvement, histology, and radiation therapy (adjusted HR, 95% CI: 1.04, 0.89-1.20). Importantly, OS was similar between ET and ECT among patients with OncotypeDX (ODX) score &lt; 26 (96.4% vs 97.5%) and ODX score ≥ 26 (5-year OS: 92.2% vs 91.4%). PS match yielded 3,002 pairs; 5-years OS remained similar between ET (92.6%) and CET (91.6%) (p=0.94). In addition, no significant difference was detected when stratifying by disease stage and histology. Conclusion In this large analysis , chemotherapy did not improve survival in patients with HR+ and HER2- lobular cancer treated with ET, regardless of stage or lymph node involvement, or ODX score. The majority of patients with early stage HR+/HER2- with ILBC in the US receive ET, and one-fourth receive CET. Research investigating de-escalated chemotherapy-free regimens for ILBC are warranted. Exploring biomarkers-based approach to identify subgroups who would benefit from chemotherapy would better define systemic treatment options for ILBC.

Citation Format: Marita Yaghi, Iktej Jabbal, Nadeem Bilani, Maroun Bou Zerdan, Leah Elson, Hong Li, Diana Saravia, Elizabeth Stone, Zeina Nahleh. Does chemotherapy benefit patients with HR+/HER2- invasive lobular breast cancer? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD14-06.

Abstract P1-08-33: Disparities in the practice of precision medicine? Using multi-gene testing in early-stage, HR+/HER2- breast cancer

Background: Multi-gene testing (MGT) can be used to identify patients with early-stage, hormone receptor-positive (HR+), HER2-negative (HER2-) breast cancer that are likely to benefit from treatment regimens with chemotherapy and endocrine therapy, compared to endocrine therapy alone. Two examples of genomic panels include OncotypeDX (ODX) MammaPrint (MP). Tailoring practice to the unique profile of each patient, known as ‘precision medicine’, has significantly refined the treatment approach in breast cancer, while decreasing toxicity and cost. In this analysis, we explore disparities in the access to precision medicine among several socio-demographic groups. Methods: We conducted a retrospective analysis of the National Cancer Database, using the 2004-2017 breast cancer dataset. We included patients with HR+/HER2-, stage I-II breast cancer. We excluded patients with stage III disease as many would still receive chemotherapy with less use of MGT. Using chi-squared statistics, we identified socio-demographic, clinical and pathologic factors associated with the use MGT - either ODX or MP - in this group. We then included significant variables (p&lt;0.05) in one multiple logistic regression model predicting the use of either genomic panel. Results: A total of n=841,716 patients who were candidates for MGT (early-stage, HR+/HER2- breast cancer) were included in this analysis. N=283,833 (n=33.7%) underwent MGT (32.2% used ODX while 1.5% used MP). Use of genomic assays has increased significantly over time (11.5% for patients diagnosed between 2007-2009, to 39.4% between 2016-2017). Variables significantly associated with the use of either ODX/MP at the multivariate level (p&lt;0.05) included: age, race, insurance status, education level, facility type, year of diagnosis, geographic location, tumor grade, and tumor histology. Elderly patients (&gt;70) were less likely than those &lt;50 to undergo MGT (OR 0.32, 95% CI 0.32-0.33, p&lt;0.001). Black patients were also less likely to receive a genomic assay compared to White patients (OR 0.80, 95% CI 0.78-0.82, p&lt;0.001). Insurance status was another significant predictor, with uninsured patients being the least likely to receive ODX or MP (OR 0.69, 95% CI 0.66-0.72, p&lt;0.001), compared to those with private insurance. Conversely, patients treated at academic/research cancer programs were more likely to undergo MGT than those treated at community cancer programs (OR 1.13, 95% CI 1.10-1.15, p&lt;0.001). Geographic discordance in use of MGT was also identified: with highest rates of use (39.2%) in the Middle Atlantic (NJ, NY, PA), and lowest rates (23.5%) in West South-Central states (AR, LA, OK, TX). Conclusions: This large analysis of real world, national data identified several social determinants of health predictive of disparity in the implementation of precision medicine practices for early-stage, HR+/HER2- breast cancer. Improving access to innovative, diagnostic and prognostic tools, among black and underinsured patients, as well as those treated in community practices, is needed.

Citation Format: Nadeem Bilani, Marita Yaghi, Diana Saravia, Iktej Jabbal, Maroun Bou Zerdan, Leah Elson, Liang Hong, Zeina Nahleh. Disparities in the practice of precision medicine? Using multi-gene testing in early-stage, HR+/HER2- breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-08-33.

Fertility in multiple recurrent bilateral ovarian teratomas: A case report

Very few cases of bilateral and recurrent teratomas have been reported. We present the case of a 21-year-old nulliparous female who presented to an outside facility complaining of left flank pain and was found to have bilateral ovarian teratomas. The physician proceeded with a laparotomy. Five years later, the patient presented to our facility complaining of abdominal pain. Imaging revealed a second incidence of bilateral dermoid cysts for which she underwent a bilateral laparoscopic cystectomy. The patient retained her fertility and was able to deliver a newborn 2 years later. At the age of 31, and during a regular check-up, the patient was found again to have a third incidence of bilateral dermoid cysts for which she underwent bilateral laparoscopic cystectomy with preservation of her ovaries. In conclusion, laparoscopic removal of dermoid cysts is of utmost importance to retain the fertility of young patients. Regular check-up by ultrasound post-operatively is necessary to screen for recurrences and prevent painful presentations.

Everolimus in poorly differentiated neuroendocrine carcinoma of unknown primary: A case report

Malignancies with unknown primaries contribute to a small yet significant percentage of overall tumors. Neuroendocrine carcinomas, a rare disease with a poor prognosis, have been known to present as an unknown primary. Treatment consists of cytotoxic chemotherapy but given the latter’s high toxicity profile new treatment options are being explored. In this case report, we describe a case of a patient with poorly differentiated neuroendocrine carcinoma of unknown primary treated with compassionate oral everolimus after his refusal of intravenous chemotherapy.

Glioblastoma multiforme metastasizing to the skin, a case report and literature review

Glioblastoma Multiforme (GBM) is the most common primary central nervous system (CNS) malignancy in adults. It is very aggressive and is notorious for its fast and local invasion of nearby brain parenchyma. Consequently, the overall survival (OS) of patients with GBM is short despite resection, radiotherapy and chemotherapy regimens. The most common sites of metastasis of GBM are the lungs and pleura, cervical lymph nodes, and bone. Metastasis to the skin is a rare event and to our knowledge, there are less than 30 cases of GBM metastasizing to cutaneous or subcutaneous tissue described in the literature. None of these cases were diagnosed and/or treated in the Middle East region; and the majority of the metastases found were adjacent to the site of surgery undergone to remove the primary malignancy. We present the case of a 53-year-old male diagnosed with GBM and later showing signs of metastases at the anterio-auricular side of his face near-distant from the site of previous surgery done to remove the primary tumor.

Diagnostic Performance of FDG-PET/CT Scan as Compared to US-Guided FNA in Prediction of Axillary Lymph Node Involvement in Breast Cancer Patients

Purpose

The aim of this study was to evaluate the diagnostic ability of 2-deoxy-2-[fluorine-18]fluoro-d-glucose (¹⁸F-FDG) PET/non-contrast CT compared with those of ultrasound (US)-guided fine needle aspiration (FNA) for axillary lymph node (ALN) staging in breast cancer patients.

Patients and Methods

Preoperative ¹⁸F-FDG PET/non-contrast CT was performed in 268 women with breast cancer, as well as ALN dissection or sentinel lymph node (SLN) biopsy. One hundred sixty-four patients underwent US-guided FNA in combination with ¹⁸F-FDG PET/CT. The diagnostic performance of each modality was evaluated using histopathologic assessments as the reference standard. The receiver operating characteristic (ROC) curves were compared to evaluate the diagnostic ability of several imaging modalities.

Results

Axillary ¹⁸F-FDG uptake was positive in 180 patients, and 125 patients had axillary metastases according to the final pathology obtained by ALN dissection and/or SLN dissection. Of the patients with positive ¹⁸F-FDG uptake in the axilla, 21% had false-positive results, whereas 79% were truly positive. Eighty-eight patients had negative ¹⁸F-FDG uptake in the axilla, among which 25% were false-negative. ¹⁸F-FDG-PET/CT had a sensitivity of 86.59% and a specificity of 63.46% in the assessment of ALN metastasis; on the other hand, US-guided FNA had a sensitivity of 91.67% and a specificity of 87.50%. The mean primary cancer size (p = 0.04) and tumor grade (p = 0.04) in combination were the only factors associated with the accuracy of ¹⁸F-FDG PET/CT for detecting metastatic ALNs.

Conclusion

The diagnostic performance of ¹⁸F-FDG PET/CT for the detection of axillary node metastasis in breast cancer patients was not significantly different from that of US-guided FNA. Combining ¹⁸F-FDG PET/CT with US-guided FNA or SLN biopsy could improve the diagnostic performance compared to ¹⁸F-FDG PET/CT alone.

Oligodendroglioma: A Review of Management and Pathways

Anaplastic oligodendrogliomas are a type of glioma that occurs primarily in adults but are also found in children. These tumors are genetically defined according to the mutations they harbor. Grade II and grade III tumors can be differentiated most of the times by the presence of anaplastic features. The earliest regimen used for the treatment of these tumors was procarbazine, lomustine, and vincristine. The treatment modalities have shifted over time, and recent studies are considering immunotherapy as an option as well. This review assesses the latest management modalities along with the pathways involved in the pathogenesis of this malignancies.

Race, insurance status and treating facility type associated with completeness of medical record in patients with breast cancer

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Background: The National Cancer Database (NCDB) is a large registry that collates real-world medical record data from millions of patients in the United States. A previous published study using the NCDB found that gaps in the medical record were associated with worse overall survival outcomes. We investigated cases of breast cancer in this registry to understand which factors were predictive of records with missing data. Methods: We screened for missing data in 54 clinical parameters documented by the NCDB pertaining to the diagnosis, workup, management and survival of patients with breast cancer diagnosed between 2004 and 2017. We performed univariate statistics to describe gaps in the dataset, followed by multivariate logistic regression modeling to identify factors associated lack of completeness of the medical record – defined as the presence of > 3 missing variables. Results: A total of n = 2,981,732 patients were included in this analysis. The median number of missing variables per record was 3 (5.6% of clinical parameters surveyed). 52.1% of records had ≤ 3 variables missing, while 47.9% had > 3 variables missing. Predictors of a record with missing data in > 3 variables were: age, race, insurance status and facility type . Regarding race, we found that records of Asian patients were less likely to have missing data as compared to records of White patients (OR 0.75, 95% CI: 0.74-0.76, p < 0.001). Conversely, there was no difference in completeness of the medical record between Black and White patients (OR 0.99, 95% CI: 0.99-1.01, p = 0.890). Patients with private insurance (OR 0.77, 95% CI 0.76-0.79, p < 0.001), or Medicaid (OR 0.65, 95% CI 0.64-0.67, p < 0.001) or Medicare (OR 0.66, 95% CI 0.64-0.67, p < 0.001) were also less likely to have missing data compared to uninsured patients, with patients on private insurance being the least likely to have incomplete records. Finally, patient records from academic programs (OR 0.91, 95% CI 0.90-0.92, p < 0.001) were less likely to contain > 3 missing variables compared to records from patients treated at community cancer programs. Conclusions: Despite high fidelity of NCDB data, social determinants of health including insurance status and treating facility type, were associated with differences in the completeness of the medical record. Improvements in documentation and data quality are necessary to optimize use of real-world data in cancer registries. Further research is needed to determine how these differences could be independently associated with inferior outcomes.

Geographic location and other determinants of patient decision-making to decline chemotherapy in advanced breast cancer

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Background: Much work has been done to explore how social determinants of health are associated with disparities in the use of chemotherapy for breast cancer. We used a large national registry to explore whether patient decision-making to accept or decline chemotherapy varies geographically across the United States. Methods: This analysis used the National Cancer Database to study decision-making in patients diagnosed with advanced breast cancer (AJCC clinical stage III-IV) between 2004-2017. We identified patients recommended chemotherapy by their physicians, but who declined treatment. We performed multivariate logistic regression modeling to explore variables associated with the decision to decline chemotherapy. Results: A total of n = 167,647 patients with stage III-IV breast cancer were included. After controlling for age, race, ethnicity, Charlson/Deyo comorbidity scoring, receptor status, histology, grade, patient education, insurance status, and facility type, geographic region was found to be significantly associated with the decision to either accept or decline chemotherapy (p < 0.001). Patients in the New England area (i.e. CT, MA, ME, NH, RI and VT) exhibited the highest rate of refusal of chemotherapy (9.3%). In contrast, patients in East South Central states (i.e. AL, KY, MS, TN) were the least likely to decline chemotherapy at 5.5% rate of refusal (OR 0.55, 95% CI: 0.47-0.66, p < 0.001). Rates of refusal were lower for patients with TNBC at 4.1% versus 7.7% in those with HR+/HER2 tumors. Patients aged > 70 had increased odds of declining chemotherapy (OR 9.30, 95% CI: 8.17-10.59, p < 0.001) compared to patients < 50. Race and level of education were not associated with patient decision-making in this cohort, however, Hispanics had lower odds (OR 0.70, 95% CI: 0.60-0.82, p < 0.001) of refusing chemotherapy as compared to Non-Hispanics. Patients with higher comorbidity were also more likely to decline chemotherapy (p < 0.05). As compared to the uninsured, Medicare-insured (OR 0.69, 95% CI: 0.60-0.80, p < 0.001), Medicaid-insured (OR 0.65, 95% CI: 0.56-0.76, p < 0.001) and privately-insured patients (OR 0.39, 95% CI: 0.33-0.44, p < 0.001) were less likely to decline chemotherapy. Lastly, patients treated at academic institutions (OR 0.90, 95% CI: 0.81-0.99, p = 0.029) were less likely to decline chemotherapy compared to those in community cancer programs. Conclusions: This study showed that after adjusting for known social determinants of health, there was a significant difference in rates of refusal of recommended chemotherapy by geographic region, with highest refusal rates in New England states. Of interest, Hispanic ethnicity was associated with lower likelihood to decline chemotherapy, while uninsured status was associated with increased refusal. Researching this geographic differential further will help improve efficacy of care delivery in patients with cancer.

Mechanisms of Immunotoxicity: Stressors and Evaluators

The immune system defends the body against certain tumor cells and against foreign agents such as fungi, parasites, bacteria, and viruses. One of its main roles is to distinguish endogenous components from non-self-components. An unproperly functioning immune system is prone to primary immune deficiencies caused by either primary immune deficiencies such as genetic defects or secondary immune deficiencies such as physical, chemical, and in some instances, psychological stressors. In the manuscript, we will provide a brief overview of the immune system and immunotoxicology. We will also describe the biochemical mechanisms of immunotoxicants and how to evaluate immunotoxicity.

Drug-Induced Peripheral Neuropathy: Diagnosis and Management

Peripheral neuropathy comes in all shapes and forms and is a disorder which is found in the peripheral nervous system. It can have an acute or chronic onset depending on the multitude of pathophysiologic mechanisms involving different parts of nerve fibers. A systematic approach is highly beneficial when it comes to cost-effective diagnosis. More than 30 causes of peripheral neuropathy exist ranging from systemic and auto-immune diseases, vitamin deficiencies, viral infections, diabetes, etc. One of the major causes of peripheral neuropathy is drug induced disease, which can be split into peripheral neuropathy caused by chemotherapy or by other medications. This review deals with the latest causes of drug induced peripheral neuropathy, the population involved, the findings on physical examination and various workups needed and how to manage each case.

Olaratumab's failure in soft tissue sarcoma

Soft tissue sarcomas remain one of the rarest malignancies with numerous subtypes that go undiagnosed. The PDGFRα antagonist Olaratumab (Lartruvo) was withdrawn from the market due to disappointing findings in the phase III studies. We share our experience with this medication in a tertiary care center in the Middle East and North Africa region. Monitor the effect of Olaratumab on sarcomas when it was used prior to its withdrawal, and compare our findings with the literature. We performed a retrospective analysis of adult patients with advanced-/metastatic soft tissue sarcomas treated with at least two cycles of Olaratumab at a tertiary care center in Lebanon during the period from January 1, 2017 to December 31, 2018. Fifteen patients were included in the study. The mean age was 49 with a range of 26–75 years. The median duration of the use of Olaratumab was 21.3 months with a range of 7.3–37 months. The average number of number of cycles received per patient was four. Five patients were deceased. Median PFS was 7.87 months (95% CI 5.28–10.45), and mean OS was 12.26 months (95% CI 8.47–16.05) Median OS was 9.8 months (95% CI 6.07–13.53). Olaratumab has been withdrawn from the market, and it is currently being investigated as part of the phase II ANNOUNCE 2 trial. Our experience from a tertiary care center shows results similar to those reported in the literature. The immunogenicity and heterogeneity of soft tissue sarcomas pose a challenge to the treatment of soft tissue sarcomas, but they also allow a wide array of possible management solutions.

Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in the Middle East (Kuwait, Lebanon and Saudi Arabia): data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Kuwait, Lebanon and Saudi Arabia.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 139 S. pneumoniae isolates were collected from four centres in Kuwait, Lebanon and Saudi Arabia in 2015-17 and 55 H. influenzae isolates were collected and analysed from Saudi Arabia over the same time period. Pneumococci from all three countries were commonly non-susceptible to penicillin based on CLSI oral or low-dose IV penicillin using EUCAST breakpoints (39% in Kuwait to 57.1% in Lebanon) but by CLSI IV and EUCAST high-dose breakpoints most isolates were susceptible (∼90% in Kuwait and Saudi Arabia, and 100% in Lebanon). Isolates from Lebanon were highly susceptible to most other antibiotics (>90%) except cefaclor, oral cefuroxime and cefpodoxime (EUCAST breakpoints only). Overall, susceptibility was significantly lower in Kuwait and Saudi Arabia than Lebanon. Although all H. influenzae isolates (Saudi Arabia only) were β-lactamase negative, 3.6% and 12.7% were ampicillin resistant by CLSI and EUCAST breakpoints, respectively. Otherwise susceptibility was high in H. influenzae. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Relatively low antibiotic susceptibility was observed in S. pneumoniae from Kuwait and Saudi Arabia in contrast to Lebanon, where rates of susceptibility were generally higher. Isolates of H. influenzae from Saudi Arabia were susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.