Breast cysticercosis - a case report

SUMMARY

Isolated incidences of human cysticercosis have been reported world-wide, but it remains a major public health concern in endemic areas such as Mexico, Africa, South-East Asia, Eastern Europe, and South America. Cysticercosis most commonly involves the skeletal muscle, subcutaneous tissue, brain, and eyes. The breast is an uncommon site of presentation for cysticercosis. Due to its rare occurrence, breast cysticercosis is often initially mistaken for other common breast lesions such as cysts, abscess, malignant tumours and fibroadenomas. We report a case of breast cysticercosis in a young South African woman.

Dysregulation of systemic soluble immune checkpoints in early breast cancer is attenuated following administration of neoadjuvant chemotherapy and is associated with recovery of CD27, CD28, CD40, CD80, ICOS and GITR and substantially increased levels of PD-L1, LAG-3 and TIM-3

Neoadjuvant chemotherapy (NAC) may alter the immune landscape of patients with early breast cancer (BC), potentially setting the scene for more effective implementation of checkpoint-targeted immunotherapy. This issue has been investigated in the current study in which alterations in the plasma concentrations of 16 soluble co-stimulatory and co-inhibitory, immune checkpoints were measured sequentially in a cohort of newly diagnosed, early BC patients (n=72), pre-treatment, post-NAC and post-surgery using a Multiplex® bead array platform. Relative to a group of healthy control subjects (n=45), the median pre-treatment levels of five co-stimulatory (CD27, CD40, GITRL, ICOS, GITR) and three co-inhibitory (TIM-3, CTLA-4, PD-L1) soluble checkpoints were significantly lower in the BC patients vs. controls (p<0.021-p<0.0001; and p<0.008-p<0.00001, respectively). Following NAC, the plasma levels of six soluble co-stimulatory checkpoints (CD28, CD40, ICOS, CD27, CD80, GITR), all involved in activation of CD8+ cytotoxic T cells, were significantly increased (p<0.04-p<0.00001), comparable with control values and remained at these levels post-surgery. Of the soluble co-inhibitory checkpoints, three (LAG-3, PD-L1, TIM-3) increased significantly post-NAC, reaching levels significantly greater than those of the control group. PD-1 remained unchanged, while BTLA and CTLA-4 decreased significantly (p<0.03 and p<0.00001, respectively). Normalization of soluble co-stimulatory immune checkpoints is seemingly indicative of reversal of systemic immune dysregulation following administration of NAC in early BC, while recovery of immune homeostasis may explain the increased levels of several negative checkpoint proteins, albeit with the exceptions of CTLA-4 and PD-1. Although a pathological complete response (pCR) was documented in 61% of patients (mostly triple-negative BC), surprisingly, none of the soluble immune checkpoints correlated with the pCR, either pre-treatment or post-NAC. Nevertheless, in the case of the co-stimulatory ICMs, these novel findings are indicative of the immune-restorative potential of NAC in early BC, while in the case of the co-inhibitory ICMs, elevated levels of soluble PD-L1, LAG-3 and TIM-3 post-NAC underscore the augmentative immunotherapeutic promise of targeting these molecules, either individually or in combination, as a strategy, which may contribute to the improved management of early BC.

Systemic Immune Dysregulation in Early Breast Cancer Is Associated With Decreased Plasma Levels of Both Soluble Co-Inhibitory and Co-Stimulatory Immune Checkpoint Molecules

Breast cancer cells exploit the up-regulation or down-regulation of immune checkpoint proteins to evade anti-tumor immune responses. To explore the possible involvement of this mechanism in promoting systemic immunosuppression, the pre-treatment levels of soluble co-inhibitory and co-stimulatory immune checkpoint molecules, as well as those of cytokines, chemokines, and growth factors were measured in 98 newly diagnosed breast cancer patients and compared with those of 45 healthy controls using multiplex bead array and ELISA technologies. Plasma concentrations of the co-stimulatory immune checkpoints, GITR, GITRL, CD27, CD28, CD40, CD80, CD86 and ICOS, as well as the co-inhibitory molecules, PD-L1, CTLA-4 and TIM-3, were all significantly lower in early breast cancer patients compared to healthy controls, as were those of HVEM and sTLR-2, whereas the plasma concentrations of CX3CL1 (fractalkine), CCL5 (RANTES) and those of the growth factors, M-CSF, FGF-21 and GDF-15 were significantly increased. However, when analyzed according to the patients’ breast cancer characteristics, these being triple negative breast cancer (TNBC) vs. non-TNBC, tumor size, stage, nodal status and age, no significant differences were detected between the plasma levels of the various immune checkpoint molecules, cytokines, chemokines and growth factors. Additionally, none of these biomarkers correlated with pathological complete response. This study has identified low plasma levels of soluble co-stimulatory and co-inhibitory immune checkpoint molecules in newly diagnosed, non-metastatic breast cancer patients compared to healthy controls, which is a novel finding seemingly consistent with a state of systemic immune dysregulation. Plausible mechanisms include an association with elevated levels of M-CSF and CCL5, implicating the involvement of immune suppressor cells of the M2-macrophage/monocyte phenotype as possible drivers of this state of systemic immune quiescence/dysregulation.

Dysregulation of immune checkpoint proteins in patients with newly diagnosed early breast cancer

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Background: Checkpoint proteins regulate the immune system. Breast cancer (BC) cells can up-regulate or down-regulate these proteins to evade anti-tumor immune responses. Soluble forms of immune checkpoint molecules (ICMs) can be measured in human plasma. The study aimed to measure the systemic levels of a series of co-stimulatory and co-inhibitory ICMs at diagnosis, post-neo-adjuvant chemotherapy (NAC) and post-surgery in newly- diagnosed BC patients (pts) relative to those of a healthy control group. Methods: Soluble ICMs were measured using multiplex bead array technology in plasma from 72 BC pts and 45 healthy controls. Data was prospectively obtained and levels compared between pre-treatment, post-NAC, and post-surgery using non-parametric tests (Mann-Whitney & Kruskal-Wallis). Results: Pre-treatment levels of the soluble stimulatory molecules viz. GITR (p<0.0001), GITRL (p< 0.020), CD27 (p< 0.024), CD40 (p< 0.021), ICOS (p< 0.009), as well as the inhibitory molecules PD-L1 (p< 0.0001), CTLA-4 (p< 0.005), TIM-3 (p< 0.0004), HVEM (p< 0.0004) were significantly lower in early BC pts compared to controls. Post-treatment, there were significant increases in most ICM levels (Table), with the exception of CTLA-4, which decreased significantly following treatment. On the other hand, pre-treatment plasma concentrations of CCL5 (RANTES) (84.22 vs. 48.72 pg/mL, p<0.0001), M-CSF (84.41 vs 13.34 pg/mL, p<0.0001), FGF-21 (24.36 vs. 8.64 pg/mL, p<0.001) and GDF-15 (806.82 vs. 430.03 pg/mL, p<0.0001) were significantly increased in the breast cancer pts compared to healthy controls. A pathological complete response (pCR) was documented in 65% of pts (mostly TNBC). There were no correlations between pre-treatment ICM levels, CCL5, M-CSF, FGF-21 and GDF-15 and pCR. Conclusions: We identified low levels of stimulatory and inhibitory ICMs in newly-diagnosed, non-metastatic BC pts compared to healthy controls. Following treatment, with the exception of CTLA-4, most of these pre-treatment abnormalities of systemic ICM levels corrected. NAC is associated with upregulation of sPD-L1 and most other ICMs. These results indicate that early BC is associated with down-regulation of soluble stimulatory and inhibitory ICMs. Newly-diagnosed early BC pts appear to have generalized immune-suppression independent of subtype and stage. To our knowledge, this is the first study to describe the effect of treatment on systemic ICMs in early BC pts. [Table: see text]

Abstract P4-04-11: Dysregulation of immune checkpoint proteins in newly- diagnosed early breast cancer patients

Background: Checkpoint proteins regulate the immune system. Breast cancer (BC) cells can up-regulate or down-regulate these proteins to evade anti-tumor immune responses. Soluble forms of immune checkpoint molecules (ICMs) can be measured in human plasma. The study aimed to measure the systemic levels of a series of positive and negative ICMs at diagnosis, post-neo-adjuvant chemotherapy (NAC) and post-surgery in newly- diagnosed BC patients (pts) relative to those of a healthy control group. Method: Soluble ICMs were measured using Multiplex® bead array technology in plasma from 72 BC patients and 45 healthy controls. Data was prospectively obtained and levels compared between pre-treatment, post-NAC, and post-surgery using non-parametric tests (Mann-Whitney & Kruskal-Wallis). Results: Pre-treatment, soluble stimulatory molecules viz. GITR (p&lt;0.0000), GITRL (p&lt; 0.0199), CD27 (p&lt; 0.0243), CD40 (p&lt; 0.0209), ICOS (p&lt; 0.0087), as well as the inhibitory molecules PD-L1 (p&lt; 0.0000), CTLA-4 (p&lt; 0.005), TIM-3 (p&lt; 0.0004), HVEM (p&lt; 0.0004) levels were significantly lower in early BC pts compared to controls. Post treatment, there were significant increases in most ICM levels (Table 1), with the exception of CTLA-4 which decreased significantly following treatment. A pCR was documented in 65% of patients (mostly TNBC). There was no correlation between pre-treatment ICM levels and pCR. Conclusion: We identified low levels of stimulatory and inhibitory ICMs in newly-diagnosed, non-metastatic BC patients compared to healthy controls. Following treatment, with the exception of CTLA-4, most of these pre-treatment abnormalities of systemic ICM levels corrected. NAC is associated with upregulation of sPD-L1 and most other ICMs. These results indicate that early BC is associated with down-regulation of soluble stimulatory and inhibitory ICMs. Newly-diagnosed early BC patients appear to have generalized immune-suppression independent of subtype and stage. To our knowledge, this is the first study to describe the effect of treatment on systemic ICMs in early BC patients.

Table 1.The effect of treatment on soluble, systemic ICMsICMControlDiagnosis (Group A)Post-NAC (Group B)Post-surgery (Group C) Group A vs Group BComparing pre-treatment levels vs post-treatment levelsMedian (pg/ml)p-valueBTLA18147130229987127770,0366CD8023291678304836110,0000CD8614297115859922124390,2789CTLA-4261815665986870,0000LAG31504161312754648805001330,0000PD-L133421647479452150,0000PD-1149171230513350150760,8888TIM350473897997596150,0000CD2745773342535154270,0000CD28461353291444277500580,0415CD4019771523203020540,0002GITR37971497403544340,0000GITRL71515886533959270,4938ICOS265061512326586297460,0001HVEM22901865404739500,0000TLR2304772683133837370420,0257

Citation Format: Bernardo Leon Rapoport, Helen C Steel, Carol Ann Benn, Simon Nayler, Teresa Smit, Liezl Heyman, Annette Theron, Nomsa Hlatswayo, Luyanda Kwofie, Pieter Meyer, Ronald Anderson. Dysregulation of immune checkpoint proteins in newly- diagnosed early breast cancer patients [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 P4-04-11.

Quality of Histopathological Reporting in Breast Cancer: Results From Four South African Breast Units

PURPOSE

High-quality histopathology reporting forms the basis for treatment decisions. The quality indicator for pathology reports from the European Society of Breast Cancer Specialists was applied to a cohort from four South African breast units.

METHODS

The study included 1,850 patients with invasive breast cancer and evaluated 1,850 core biopsies and 1,158 surgical specimen reports with cross-center comparisons. A core biopsy report required histologic type; tumor grade; and estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) status, with a confirmatory test for equivocal HER2 results. Ki-67 was regarded as optional. Pathologic stage, tumor size, lymphovascular invasion, and distance to nearest invasive margin were mandatory for surgical specimens. Specimen turnaround time (TAT) was added as a locally relevant indicator.

RESULTS

Seventy-five percent of core biopsy and 74.3% of surgical specimen reports were complete but showed large variability across study sites. The most common reason for an incomplete core biopsy report was missing tumor grade (17.9%). Half of the equivocal HER2 results lacked confirmatory testing (50.6%). Ki-67 was reported in 89.3%. For surgical specimens, the closest surgical margin was reported in 78.1% and lymphovascular invasion in 84.8% of patients. Mean TAT was 11.9 days (standard deviation [SD], 10.8 days) for core biopsies and 16.1 days (SD, 11.3) for surgical specimens.

CONCLUSION

Histopathology reporting is at a high level but can be improved, especially for tumor grade, HER2, and Ki-67, as is reporting of margins and lymphovascular invasion. A South African pathology consensus will reduce variability among laboratories. Routine use of standardized data sheets with synoptic reports and ongoing audits will improve completeness of reports over time.

Abstract PS6-31: Correlations between tumor-infiltrating lymphocytes, CD3, CD8 cells, and Immunoscore®, with pathological CR and time to progression in triple-negative breast cancer patients undergoing neoadjuvant chemotherapy

Background High levels of stromal tumor-infiltrating lymphocytes (TILs) have been associated with better prognosis in early triple-negative breast cancer (TNBC). The Immunoscore® (IS) is a prognostic tool, which categorizes the densities of spatially positioned CD3 and CD8 cells in both invasive margins (IM) and the center of the tumor (CT), yielding a five-tiered classification (0-4). High IS values have been reported to predict improved outcomes in colorectal cancer. Methods The cohort consisted of 53 TNBC patients (pts) who previously received neoadjuvant anthracycline- and taxane-based chemotherapy. Quantitative analysis of the immune cells was carried out using computer-assisted image analysis in different tumor locations for CD3 and CD8 T-cell markers. Additionally, we measured stromal TILs according to the International TILs Working Group. Pre-treatment tumor samples were immune-stained for CD3 and CD8 T-cell markers and stromal TILs. The relationship between various clinical-pathological factors, and immune factors, was analyzed by Chi2 and Fischer exact test. The log-rank test and the Kaplan Meyer methods were used to estimate relapse-free survival. Results The median age of the pts was 50 years (27-84 years). Tumor sizes were categorized as T1 = 9 pts (17%), T2 = 41 pts (77%) and T3 = 3 pts (6%). Pts with positive glands = 19 (36%) pts and pts without gland involvement = 34 (64%). Stage grouping included stage 1 = 5 (9%), stage IIA = 33 (63%) pts, stage IIB = 9 (17%) pts, stage III = 6 (11%) pts. The median Ki-67 was 45% (range 5 - 90%). The median density of CD3 CT cells = 1190mm² (range 34 - 4614), CD3 IM = 1855mm² (range 57 - 6190), CD8 CT 508mm² (range 17 - 2486) and CD8 IM 805mm² (range 90 - 3156). The median percentage of stromal TILs was 5% (0 - 60%). Pts with an IS of 0 = 4 pts (8%), IS 1 = 3 (5%), IS 2 = 20 pts (38%), IS 3 = 24 pts (45%) and IS 4 = 2 pts (4%). The pathological complete response (pCR) rate of the entire cohort was 62%. A positive correlation was found between TILs and CD3 CT (R = 0.641, p &lt; 0.0000), CD8 CT (R = 0.5623, p &lt; 0.0000), CD3 IM (R = 0.6099, p &lt; 0.0000), and CD8 IM. (R = 0.5010, p &lt; 0.0010). TILs correlated with IS (R = 0,3603, p &lt; 0.0087). There was no correlation between TILs and Ki-67 (R = 0.1497, p &lt; 0.2943). On univariate analysis, factors associated with higher pCR included nodal status (positive = 42,11% vs. negative = 73,53% (p&lt;0,02362) and Ki67 &lt;40%= 33,33% vs. ≥40% = 76,47% (p&lt;0,00235). A high density of CD3 (&gt; than 1100mm2) and CD8 (&gt; than 400mm2) positive T-cells in the CT was associated with higher pCR (CD3 CT: 30% vs. 70%, p=0.00489 and CD8 CT: 30% vs. 70%, p=0.03344). Analysis of CD3 (&gt; than 1200mm2) (CD3 IM: 12% vs 88%, p=0.0.02367) and CD8 in the IM (&gt; than 550mm2) was also significant for an association with pCR (CD8 IM: 23% vs. 77%, p=0.03). High IS (3+4= 73%) vs. intermediate (2=55%) vs. low (0+1=43%) showed a numerical difference that did not, however, reach a statistical significance with pCR (p=0.111). Analysis of TILs ≥ 20% showed a pCR of 76% compared to pts with TILs &lt; 20% with a pCR of 54% (p &lt; 0.12295). A Ki67 ≥40% was associated with a pCR of 76% compared to pts with Ki67 &lt; 40% with a pCR 33% (p &lt; 0.00235). The median time to progression (TTP) of the pts not attaining a pCR was 1600 days compared to those who did attain a pCR with a median PFS not reached yet, but exceeding 1800 days. The TTP of pts with Ki67 &lt; 40% was 1700 days, while the pts with Ki67 ≥40% was not been reached (p &lt; 0.03). At 1800 days, 95% of pts with CD3 &gt; 1100mm2 did not relapse, compared to 75% pts with CD3 ≤ 1100 (p &lt; 0.03). Conclusions This exploratory study shows that analyzing CD3 and CD8 cells in the center of the tumor and invasive margin might be more useful than examining TILs in TNBC pts. Further prospective, well-designed, adequately powered studies are required to confirm these findings.

Citation Format: Bernardo Leon Rapoport, Jérôme Galon, Simon Nayler, Aurelie Fugon, Isabelle Boquet, Marine Martel, B Mlecnik, Carol Ann Benn, Teresa Smit, Liezl Heyman, Farhana Moosa, Ronald Anderson. Correlations between tumor-infiltrating lymphocytes, CD3, CD8 cells, and Immunoscore®, with pathological CR and time to progression in triple-negative breast cancer patients undergoing neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-31.

Abstract PS17-36: Dysregulation of soluble immune checkpoint proteins in newly - diagnosed early breast cancer patients

Background: Checkpoint proteins regulate the immune system. Breast cancer (BC) cells exploit the up-regulation or down-regulation of these proteins to evade anti-tumor immune responses. Soluble forms of immune checkpoint molecules (ICM) can be measured in human plasma. However, their biological and clinical significance remains mostly unknown. The aim of the present analysis was to measure the levels of pre-treatment ICM in newly diagnosed BC patients (pts) and compare them to healthy controls. Method: Soluble forms of ICM, as well as cytokines and chemokines, were measured using Multiplex® bead array and ELISA technologies. Plasma samples from 98 BC pts and 45 healthy controls were analyzed for each protein. Data was prospectively obtained. Measured levels were compared between BC pts and healthy controls using a non-parametric test (Mann-Whitney). Results: Soluble stimulatory molecules GITR (p &lt; 0.000002), GITRL (p &lt; 0.007), CD27 (p &lt; 0.002), CD28 (p &lt; 0.003), CD40 (p &lt; 0.003), CD80 (p &lt; 0.009), ICOS (p &lt; 0.0006) as well as inhibitory molecules PD-L1 (p &lt; 0.0000001), CTLA-4 (p &lt; 0.005), TIM-3 (p &lt; 0.00006), HVEM (p &lt; 0.00002) and TLR-2 (p &lt; 0.05) levels were significantly lower in early BC pts compared to healthy controls. When analyzed according to BC characteristics (TNBC vs. non-TNBC, tumor size, stage, nodal status and age) no significant difference was detected between the soluble levels of these ICM and between the different subsets. Additionally, serum levels of CXCL5 (p &lt; 0.000001), CCL23 (p &lt; 0.04), IL-16 (p &lt; 0.00005), interferon-α (p &lt; 0.03) and IL1-RA (p &lt; 0.03) were significantly lower compared to healthy controls. Serum CX3CL1 or fractalkine (p &lt; 0.024465) was significantly higher compared to healthy controls. Conclusion: In the current study, we identified low levels of both stimulatory and inhibitory soluble immune checkpoint molecules in newly diagnosed, non-metastatic BC pts compared to healthy controls. These results indicate that early BC is associated with a down-regulation of both soluble stimulatory and inhibitory immune-checkpoint pathways. Newly diagnosed early BC pts have a generalized immune-suppression independent of subtype and stage, which, to our knowledge, is the first study to describe soluble immune checkpoints in early BC pts.

Citation Format: Bernardo Rapoport, Helen Steel, Teresa Smit, Liezl Heyman, Annette Theron, Nomsa Hlatswayo, Luyanda Kwofie, Lidia Jooste, Farhana Moosa, Carol Ann Benn, Simon Nayler, Ronald Anderson. Dysregulation of soluble immune checkpoint proteins in newly - diagnosed early breast cancer patients [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS17-36.

A Rare Case of Synchronous Waldenström's Macroglobulinemia and Cutaneous Squamous Cell Carcinoma with a Lung Mass: A Diagnostic and Management Dilemma

Cutaneous squamous cell carcinoma has presented an increasing burden globally, with the occurrence of metastatic cutaneous squamous cell carcinoma being a relatively rare event but presenting with significant challenges in management, and a paucity of treatment options. Waldenström's macroglobulinemia is similarly an infrequent diagnosis. We present a rare case of a synchronous diagnosis of cutaneous squamous cell carcinoma and Waldenström's macroglobulinemia with an associated lung mass with squamous differentiation. The considered origin of the lung mass was either metastatic cutaneous squamous cell carcinoma or a primary squamous cell carcinoma of the lung, representing a third primary malignancy. The report highlights complexities in diagnosis and management, particularly in a patient with multiple synchronous malignancies. It further emphasizes the need for expanded global availability of specific therapies, including PD-1 inhibitors.

Abstract P1-10-14: Focus on tumor infiltrating lymphocytes (TIL’s): High levels of spatially positioned CD3 and CD8 cells and high immunoscores are significantly associated with pathological complete responses in triple-negative breast cancer patients

Background: The presence of high levels of tumor infiltrating lymphocytes (TIL’s) has been associated with better prognosis in early triple-negative breast cancer (TNBC). The Immunoscore is a prognostic tool, which categorizes the densities of CD3 and CD8 cells in both invasive margins (IM) and the center of the tumor (CT) yielding a five-tiered classification (0-4). High immunoscores have been reported to predict improved outcomes in patients (pts) with colorectal cancer. Methods: The final retrospective report to be presented at the meeting will evaluate the immunoscore in 106 breast cancer (BC) patients undergoing neo-adjuvant chemotherapy. The current analysis include the results of the first 63 pts (TNBC=35, Luminal=20, Her2+=8) who received treatment with anthracycline and/or taxane and/or trastuzumab-based neo-adjuvant chemotherapy. Results: Pre-treatment tumor samples were immune-stained for T-cell (CD3, CD8) markers and quantitative analysis of the immune cells was carried out using a computer-assisted image analysis in different tumor locations. Results: A pathological complete response (pCR) was documented in 57%, 63% and 10% of TNBC, Her2-positive and luminal pts respectively. T-cell densities were significantly higher for TNBC pts compared to non-TNBC pts. A high density (more than 800mm2) of CD3 and CD8 positive T-cells in the CT was associated with higher pCR (CD8 CT: 69% vs. 16%, p = 0.00002) (CD3 CT: 57% vs. 14%, p=0.00015). Analysis of CD3 and CD8 in the IM (more than 500mm2) was also significant for an association with pCR (CD8 IM: 68% vs. 23%, p = 0.002) (CD3 IM: 68% vs. 16%, p=0.0005). In subgroup analyses, TNBC high density (more than 500mm2) of CD3 CT: 72% vs. 20%, p = 0.004 and CD8 CT: 78% vs. 35%, p = 0.001 was also significant for pCR. The immunoscore was also positively correlated with pCR (P=0.0002), and with clinical response (CR, PR, PD) (P=0.002). High immunoscore pts were at low risk of relapse, with 5-year TTR rates of 87.5 % (CI, 67-100 %) as compared to 54.9 % (CI, 29.6-100 %) in low immunoscore pts (HR=4.8 (CI 1.7-13.5), P&lt;0.03). Conclusion: The results of this ongoing study show a significant prognostic and potentially predictive role for the immunoscore in BC pts, particularly in the TNBC subset.

Citation Format: Bernardo Leon Rapoport, Simon Nayler, Jerome Galon, B Mlecnik, Teresa Smit, Jacqui Barnard-Tidy, Aurelie Fugon, Marine Martel, Ronwyn I Van Eeden, Ronald Anderson, Carol Benn. Focus on tumor infiltrating lymphocytes (TIL’s): High levels of spatially positioned CD3 and CD8 cells and high immunoscores are significantly associated with pathological complete responses in triple-negative breast cancer patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-10-14.

Abstract P2-16-20: Treatment outcomes in triple negative breast cancer patients undergoing neoadjuvant chemotherapy. The importance of Ki-67

Aim of study: The aim of this retrospective project is to evaluate the treatment outcomes including pathological complete response (pCR), time to progression and overall survival in patients (pts) treated with taxane, and/or anthracycline/alkylating agents based neoadjuvant chemotherapy (NAC).

Background: Ki-67 immunohistochemical determination is a widely used biomarker of cell proliferation in pts undergoing endocrine treatment for breast cancer. The role of Ki-67 in triple negative breast cancer (TNBC) pts undergoing NAC for early disease remains controversial. Pathological Complete Response following NAC has been proposed as a prognostic indicator of long-term outcome.

Methods: We analyzed retrospectively data on 86 pts with TNBC. Pathological complete response (pCR) was defined as the complete disappearance of the invasive cancer in the breast and absence of tumor in the axillary lymph nodes examined by axillary clearance. The purpose of this analysis was to investigate factors associated with combined pCR.

Results: There were 35 pCR’s (40.7%). At 2 years 82% of pts who attained a pCR were disease free compared to 67% of pts who did not attain a pCR (log rank test p &lt; 0.0117). On univariate analysis factors associated with higher combined pCR included primary tumor size (T1=84% vs T2 and T3 =50% of pts, chi2= 6.81, p&lt;0.03317), Ki67 (&gt;30=68% vs. eq or &lt; 30%= 18% of pts, p&lt;0.00020), age (&lt; than 50 =71% vs. equal or &gt;50 =44% of pts), tumor grade (1=88% vs. 2=60% vs. 3=44% of pts, chi2 = 6.2560 p&lt;0.04381) and stage (I= 89% vs. IIA=60% vs. IIB=46% vs. III=40% of pts, p&lt;0.01350). Factors not associated with a higher pCR included menopausal status, extranodal spread and lympho-vascular invasion. In a logistic regression model Ki-67 as a continuous variable (p&lt;0.012577) and age &lt; than 50 (p&lt;0.03318) retained its significance; while tumor size, stage of disease, tumor grade loss significance.

Conclusion: Ki67 and age are independent prognostic factors of pCR in pts with early TNBC undergoing NAC.

Citation Format: Bernardo Leon Rapoport, Jacqui Barnard-Tidy, Ronwyn van Eeden, Teresa Smit, Simon Nayler, Carol Benn. Treatment outcomes in triple negative breast cancer patients undergoing neoadjuvant chemotherapy. The importance of Ki-67 [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-16-20.

Abstract P1-15-25: Prognostic factors associated with pathological complete response in early breast cancer patients undergoing neoadjuvant chemotherapy. The importance of Ki-67 and molecular subtype

Background: Ki-67 immunohistochemical determination is a widely used biomarker of cell proliferation in patients (pts) undergoing endocrine treatment for breast BC. The role of Ki-67 in pts undergoing neoadjuvant chemotherapy (NAC) for early BC remains controversial.

Methods: We analyzed retrospectively data on 137 patients undergoing taxane and/or anthracycline, transtuzumab based NAC. Luminal A was documented in 6 pts, Luminal B in 29 pts, Her-2 positive in 30 pts and triple negative breast cancers (TNBC) in 72 pts. Pathological complete response (pCR) was defined as the complete disappearance of the invasive cancer in the breast and absence of tumor in the axillary lymph nodes examined by axillary clearance.

Results: The pCR rate of the entire cohort was 41.6%. At 2 years 92% of pts who attained a pCR were disease free compared to 80% of pts who did not attain a pCR (log rank test p &lt; 0.0147).

On univariate analysis factors associated with higher pCR included primary tumor size (T1 68% vs. T2 41% vs. T3 or T4 0%, Chi2=20.05, p&lt;0.00017), nodal disease (N0 49% vs. N1 39% vs. N2 8%, p&lt;0.02948), ER receptor status (negative 59% vs. positive 14%, p&lt;0.00000), PR receptor status (negative 53% vs. positive 17%, p&lt;0.00002), molecular subtype (TNBC 53.4%, Her2=50% and Luminal A + B was 8.5%, p&lt;0.00002), Ki67 (&gt;40=55% vs. 15-39=34% vs. &lt;15=0%, p&lt;0.00060) and Stage (I= 85% vs. IIA=49% vs. IIB=36% vs. III=5%, p&lt;0.00006). Factors not associated with a higher pCR included age, menopausal status, extranodal spread and lympho-vascular invasion. In a logistic regression model Ki-67 as a continuous variable (p&lt;0.01203) and molecular subtype (p&lt;0.02228) retained its significance; while tumor size, stage of disease, nodal status, ER and PR loss significance.

Conclusion: Ki67 and molecular subtype (Her-2 positive disease and TNBC) are independent prognostic factors of pCR in pts with early BC undergoing NAC.

Citation Format: Rapoport BL, Barnard-Tide J, Smit T, Nayler S, Benn C-A. Prognostic factors associated with pathological complete response in early breast cancer patients undergoing neoadjuvant chemotherapy. The importance of Ki-67 and molecular subtype [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-25.

Association of Adipose Tissue Inflammation With Histologic Severity of Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

The prevalence of nonalcoholic fatty liver disease (NAFLD) has increased with the obesity pandemic. We analyzed the transcriptional profiles of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT), and phenotypes and functional characteristics of adipocyte tissue macrophages (ATMs), in obese patients undergoing bariatric surgery.

METHODS

We collected anthropometric data; plasma samples; and SAT, VAT, and liver tissues from 113 obese patients undergoing bariatric surgery at academic hospitals in Europe (Antwerp and Leuven) and South Africa. Based on clinical and histologic features, patients were assigned to the following groups: obese, NAFLD, nonalcoholic steatohepatitis (NASH), or NASH with fibrosis. Microarray analyses were performed to identify genes expressed differentially among groups. We measured levels of cytokines and chemokines in plasma samples and levels of RNAs in adipose tissues by quantitative reverse-transcription polymerase chain reaction. ATMs were isolated from patients and 13 lean individuals undergoing cholecystectomy (controls), analyzed by flow cytometry, and cultured; immunophenotypes and levels of cytokines and chemokines in supernatants were determined.

RESULTS

We observed increased expression of genes that regulate inflammation in adipose tissues from patients with NAFLD and NASH; expression of these genes increased as disease progressed from NAFLD to NASH. We found 111 genes associated with inflammation that were expressed differentially between VAT and SAT. Serum levels of interleukin 8, chemokine (C-C motif) ligand 3, and tumor necrosis factor-α correlated with liver inflammation and NAFLD activity score. We developed 2 models that could be used to determine patients' liver histology based on gene expression in VAT and SAT. Flow cytometry showed increased proportions of CD11c+CD206+ and CCR2+ macrophages in VAT from patients with NASH, and supernatants of cultured macrophages had increased levels of cytokines and chemokines compared with controls.

CONCLUSIONS

VAT and SAT from patients with NAFLD and NASH have an increased expression of genes that regulate inflammation, and ATM produce increased levels of inflammatory cytokines, compared with adipose tissues from controls. We identified an expression profile of 5 genes in SAT that accurately predict liver histology in these patients. Transcript profiling: accession numbers: GSE58979 and GSE59045.

Large vessel adventitial vasculitis characterizes patients with critical lower limb ischemia with as compared to without human immunodeficiency virus infection

Objectives

Whether a human immunodeficiency virus (HIV)-associated vasculitis in-part accounts for occlusive large artery disease remains uncertain. We aimed to identify the histopathological features that characterize large vessel changes in HIV sero-positive as compared to sero-negative patients with critical lower limb ischemia (CLI).

Materials and Methods

Femoral arteries obtained from 10 HIV positive and 10 HIV negative black African male patients admitted to a single vascular unit with CLI requiring above knee amputation were subjected to histopathological assessment. None of the HIV positive patients were receiving antiretroviral therapy.

Results

As compared to HIV negative patients with CLI, HIV positive patients were younger (p<0.01) and had a lower prevalence of hypertension (10 vs 90%, p<0.005) and diabetes mellitus (0 vs 50%, p<0.05), but a similar proportion of patients previously or currently smoked (80 vs 60%). 90% of HIV positive patients, but no HIV negative patient had evidence of adventitial leukocytoclastic vasculitis of the vasa vasorum (p<0.0001). In addition, 70% of HIV positive, but no HIV negative patient had evidence of adventitial slit-like vessels. Whilst T-lymphocytes were noted in the adventitia in 80% of HIV positive patients, T-lymphocytes were noted only in the intima in HIV negative patients. The presence of femoral artery calcified multilayered fibro-atheroma was noted in 40% of HIV positive and 90% of HIV negative patients with CLI.

Conclusions

An adventitial vasculitis which characterizes large artery changes in CLI in HIV-infected as compared to non-infected patients, may contribute toward HIV-associated occlusive large artery disease.

Triple Negative Breast Cancer Pathologic Diagnosis and Current Chemotherapy Treatment Options

Triple negative breast cancer (TNBC) comprises 12–20 % of all breast cancers and are a heterogeneous group of tumours, both clinically and pathologically. These cancers are characterised by the lack of expression of the hormone receptors oestrogen receptor (OR) and progesterone receptor (PR), combined with the lack of either overexpression or amplification of the human epidermal growth factor receptor-2 (HER2) gene. Conventional cytotoxic chemotherapy and DNA damaging agents continue to be the mainstay of treatment of this disease in the neoadjuvant, adjuvant and metastatic setting. The lack of predictive markers in identifying potential targets for the treatment of TNBC has left a gap in directed therapy in these patients. Platinum agents have seen renewed interest in TNBC based on an increasing body of preclinical and clinical data suggesting encouraging activity. However, comparisons between chemotherapy regimens are mostly retrospective in nature and the best agents or drug combinations for TNBC have not been established in prospective randomised trials. Numerous studies have now shown that TNBC has significantly higher pathological complete response (pCR) rates compared with hormone receptor positive breast cancer when treated with neoadjuvant chemotherapy, and pCR correlates well with better outcomes for these patients. Patients with TNBC account for a larger number of deaths in the setting of metastatic breast cancer. There is no preferred treatment for the first-line metastatic setting. Although individual agents are recommended, given the often aggressive nature of TNBC and the presence of extensive visceral disease, the use of a combination of drugs, rather than a single agent, is often advocated. This review article will outline the pathological diagnosis of TNBC and the treatment options available to these patients in the neoadjuvant, adjuvant and metastatic setting, including an assessment of future directions of treatment.

Molecular characterisation of gastrointestinal stromal tumours in a South African population

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the digestive tract. Pathogenesis is linked to activating mutations identified in two proto-oncogenes, v-kit Hardy/Zuckerman 4 feline sarcoma viral oncogene homologue KIT (KIT) and the platelet-derived growth factor α (PDGFRα). In addition, these mutations affect response to treatment with tyrosine kinase inhibitors. In the present study, we report on the molecular characterisation of GISTs in the South African population. Tumour DNA was extracted from 46 GIST samples, followed by cycle sequencing of KIT exons 11, 13 and 17 and PDGFRα exons 12, 14 and 18. Fragment length analysis was used to detect a 6-bp duplication in KIT exon 9. Wild-type duplications were analysed further by PCR and sequencing of additional KIT and PDGFRα exons was performed. Overall, 78.3% of the samples had a mutation in KIT or PDGFRα. Of these, mutations were detected in KIT exon 11 (88.9%), PDGFRα exon 18 (8.3%) and KIT exon 9 (2.8%). Mutations varied from simple substitutions and duplications to large deletions (some with nucleotide insertions) resulting in missense mutations. In addition, seven single nucleotide polymorphisms were detected in 17 patients, one of which appears novel. The incidence of mutations in KIT exon 11 and PDGFRα exon 18 is consistent with the literature, however, the low incidence of KIT exon 9 mutations detected was unexpected. In contrast to previous western and Asian studies, this mutation appears to be rare in the South African population. The present study contributes to the molecular understanding of GISTs in the South African population.

Aggressive fibromatosis--impact of prognostic variables on management

OBJECTIVE

To determine the impact of prognostic variables on local control in patients with aggressive fibromatosis treated with or without radiation.

MATERIALS AND METHODS

Forty-two patients presenting to the combined sarcoma clinic at Johannesburg Hospital with aggressive fibromatosis from 1990 to 2003 were analysed retrospectively. There were 14 males and 28 females. The lesions involved the head and neck in 6 cases (14%), the thorax in 6 (14%), the extremities in 19 (45%) and the abdomen in 11 (26%). Thirty-seven patients (88%) presented to the clinic for the first time, whereas 5 (12%) had recurrent disease at presentation. Fifteen patients (36%) underwent excision only, 15 (36%) had excision followed by postoperative radiation, 8 (19%) had biopsy only, and 4 (9%) had radiation only. The median dose of radiation was 60 Gy (range 9 - 70 Gy).

RESULTS

One patient had local failure following excision and postoperative radiation therapy. The local control was 100% for surgery alone and 86% for surgery followed by postoperative radiation at > or = 24 months. On univariate analysis, age, sex, positive margins, primary or recurrent presentation, site of involvement and initial treatment did not affect local control significantly. Eight of 19 patients (42%) receiving radiation developed severe moist desquamation following treatment, and all these patients had doses of 60 Gy or more.

CONCLUSION

Surgery with or without radiation therapy gave excellent local control. The addition of radiation therapy to surgery as well as other known prognostic parameters did not impact on local control. The morbidity of radiation treatment is considerable, as noted in this series, and adjuvant radiation therapy should therefore be considered only in situations where the risk of recurrence and the morbidity of re-excision are high.

Gastrointestinal stromal tumours of the oesophagus

A rare case of gastrointestinal stromal tumour (GIST) of the oesophagus is presented. Pathological features with a review of the treatment options and the literature are presented.

Angiosarcomas--clinical profile, pathology and management

Files of 8 patients with primary angiosarcomas treated in the Department of Radiation Oncology at the University of the Witwatersrand from 1982 to 1995 were identified. None of these patients had received prior radiotherapy or chemotherapy which would have predisposed them to the formation of an angiosarcoma. Slides of 6 patients were reviewed. Five of the 6 were confirmed as having angiosarcomas, while 1 patient was found to have a peripheral neuro-epithelial tumour. Four patients had angiosarcomas of the breast, while there was 1 patient each with angiosarcoma of the skin, intestine and brain. Complete excision was the primary modality of management whenever possible. Postoperative radiotherapy was given in cases of incomplete excision, patient refusal of radical surgery or gross tumour. Four patients died within 4 months of diagnosis. Three patients are alive (2 with no evidence of disease) 22-96 months after diagnosis. In 1 patient follow-up details were not available as he did not return for treatment. Angiosarcomas are aggressive malignant tumours arising from the endothelial cells. Complete surgical excision is the treatment of choice in the management of this aggressive disease, which has a poor prognosis.

Sialadenosis: a presenting sign in bulimia

BACKGROUND

Sialadenosis refers to noninflammatory, often recurrent, enlargement of the salivary glands, most frequently the parotids, which is almost always associated with an underlying systemic disorder. These include diabetes, alcoholism, malnutrition, anorexia nervosa, and bulimia. It is thought that the various causes of sialadenosis all result in a common pathogenetic effect in that they produce a peripheral autonomic neuropathy which is responsible for disordered metabolism and secretion, resulting in acinar enlargement.

METHODS

This paper reports a case of sialadenosis as a presenting sign in bulimia and studies the histologic and electron microscopic features of this disease.

RESULTS

Light microscopy showed acini which appeared to be larger than normal and which were composed of plump pyramidal cells containing prominent zymogen granules. There was less interstitial fat, and the ducts were widely dispersed. Electron microscopy showed the acinar cells to be packed with membrane-limited, dark secretory granules some of which showed moulding of their outlines. Cellular organelles and nuclei were inconspicuous.

CONCLUSIONS

Management of sialadenosis depends upon identification of the underlying cause, which must then be corrected. In bulimia, the swellings may be refractory to standard treatment modalities, and parotidectomy may be considered as a last resort to improve the unacceptable aesthetics.

Spindle epithelial tumour with thymus-like element (SETTLE): the predominantly monophasic variant

AIMS

To describe two cases of spindle epithelial tumour with thymus-like element (SETTLE) which are composed predominantly of spindle cells. In addition, to highlight some unusual histological features in SETTLE and discuss its separation from histological mimics.

METHODS AND RESULTS

The thyroid masses were in a 4-year-old boy and a 25-year-old male. Both patients were euthyroid and were well except for thyromegaly. The specimens were formalin fixed, and immunohistochemistry was performed on this material using a panel of antibodies following microwave antigen retrieval. Morphologically, the dominant pattern was of sheets of spindle cells arranged in several patterns. There was mild pleomorphism and occasional mitoses. There were very small foci of squamous epithelium and occasional ductular structures. The stroma was composed of fibrous tissue and isolated areas of calcification were noted. The spindle cells showed strong and diffuse immunoreactivity with AE1/3, CAM5.2 and vimentin.

CONCLUSION

We describe two cases of SETTLE that are composed mainly of spindle cells and only a very focal ductular component. In addition, calcification was noted within the stroma in one of the cases. These predominantly spindle examples of SETTLE must be separated from synovial sarcoma, which is a more mitotically active, aggressive tumour displaying only patchy immunopositivity with epithelial markers.

Symmetrical multifocal liposarcoma

Multiple liposarcomas are extremely rare. We report on a patient with liposarcoma of the right lower limb who had undergone surgery and radiotherapy 4 years previously for a liposarcoma in the left lower limb. An outline of the management is discussed and a short review of available literature is given.

Bacillary angiomatosis. The first case reported in South Africa

A 28-year-old white man, positive for HIV, who was admitted to hospital for pneumonia, had for 2 months had several fluctuating cutaneous purple nodules on his legs and abdomen. Cultures of two lesions were negative, but light and electron microscopy showed organisms characteristic of bacillary angiomatosis. The patient responded well to therapy with erythromycin. This is the first reported case of bacillary angiomatosis in South Africa.