Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia

BACKGROUND

There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle.

AIM

This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India.

METHOD

A retrospective case file study was conducted across several centers in India.

RESULTS

Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions.

CONCLUSIONS

Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Motor cortical plasticity in adolescents with early onset schizophrenia: A TMS-EMG study assessing the perturbation effect of intermittent and continuous theta burst stimulation

BACKGROUND

Neuroplasticity in adolescents is distinct from that of adults. Literature pertaining to neuroplasticity in schizophrenia is limited to adult populations.

AIM

We aimed to assess baseline (or resting) cortical excitability and cortical plasticity in adolescents with schizophrenia using the transcranial magnetic stimulation-electromyography (TMS-EMG) protocol.

METHODS

Twenty adolescent cases with schizophrenia and 20 age and gender matched healthy controls were studied using a crossover design. Single pulse TMS elicited resting motor threshold (RMT) and motor evoked potentials (MEPs) were assessed. Cortical plasticity determined by tracking MEPs after a single session continuous theta burst stimulation (cTBS) and intermittent theta burst stimulation (iTBS) up to 120 minutes at 12 intervals.

RESULTS

Baseline (or resting) cortical excitability was found to be significantly lower in cases compared to controls. Response patterns to cTBS and iTBS were similar between the cross-over. While cTBS led to inhibitory response, iTBS had an excitatory effect in both the groups. In the cases, while cTBS led to significantly greater initial inhibitory response, iTBS led to significantly lower excitatory response, compared to controls. The time taken to return to baseline excitability was significantly longer after receiving cTBS for cases, compared to controls.

CONCLUSIONS

iTBS and cTBS lead to excitatory and inhibitory response, representing classical long-term depression and long-term potentiation effects, respectively, in both cases and controls. We conclude that adolescents with schizophrenia have significantly lower baseline (resting) cortical excitability as well as significantly greater inhibitory plasticity; excitatory plasticity is significantly lower.

Anxiety among pregnant women during the COVID-19 pandemic in India - A multicentric study

While higher anxiety during antenatal period cause several maternal and foetal health related complications, lower anxiety levels are found to be associated with lesser "precautionary behaviours" and consequently greater risk of infection, during the COVID-19 pandemic. In this study, we aimed to assess rates and determinants of generalized anxiety at the time of the pandemic as well as anxiety that was specific to the context of being pregnant during the COVID-19 pandemic. (COVID-19-antenatal anxiety) in Indian women. This hospital-based, cross-sectional study using face-to-face interviews was conducted at antenatal clinics of five medical college hospitals in India. The Generalized Anxiety Disorder-7 scale (GAD -7) and a customized scale to assess antenatal COVID-19 anxiety along with other tools that assessed social support and COVID-19-risk perception were administered to 620 pregnant women. We found that the percentage of women with moderate or severe anxiety based on GAD -7 was 11.1%. Multivariate analysis showed that higher COVID-19-risk perception, greater antenatal COVID-19 anxiety and lower perceived support significantly predicted moderate and severe generalized anxiety. Greater number of weeks of gestation, lower education, semiurban habitat and lower perceived social support were significant predictors of antenatal COVID-19 anxiety. We conclude that the rates of anxiety in pregnant women though not very high, still warrant attention and specific interventions.

Repetitive transcranial magnetic stimulation and its role in suicidality - A systematic review

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) as a brain stimulation modality is approved for the treatment of resistant depression and its efficacy in depression is also well supported in several studies. However, its effect on suicidality is still unclear, unlike electroconvulsive therapy.

METHODOLOGY

This paper provides a systematic review of the literature published till June 2021. Studies that used rTMS as either monotherapy or adjunctive treatment in patients with suicidality, irrespective of their diagnosis, were included. The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines was followed. A total of 20 studies (N = 1584) were included for the qualitative synthesis. The quality of studies was assessed using the Cochrane Risk of Bias tool for Randomised control trials (RCT) and the Newcastle-Ottawa Scale tool for Non-Randomised studies (NRS).

RESULTS

Of the 20 articles selected for qualitative synthesis, 11 were RCTs and 9 were NRS. The results are categorized in domains of type of the study, size of population, type of population, diagnosis, assessment scales, mode of rTMS, stimulus parameters, safety and efficacy.

CONCLUSIONS

The high frequency rTMS at left dorsolateral prefrontal cortex as an adjunct to antidepressant medication is promising in reducing suicidal behaviour in treatment resistant depression. However, role of TMS targeting other areas of stimulation in mitigating suicide risk in other disorders could not be established due to scarcity of such studies. The results should be interpreted cautiously as considerable risk of bias was present in the reviewed studies.

Abstract P2-08-02: Interaction of PIK3CA mutation subclasses with response to preoperative treatment with the PI3K inhibitor pictilisib in patients with estrogen receptor-positive breast cancer

Background: Although preclinical data suggest that combining PI3K inhibitors with endocrine therapy may overcome resistance, results from randomized clinical trials have failed to identify a subgroup of patients that derive a substantial benefit. This preoperative window study assessed whether adding the PI3K inhibitor pictilisib can increase the anti-tumor effects of anastrozole in primary breast cancer and aimed to identify the most appropriate patient population for combination therapy.

Methods: In this randomized, open-label, phase 2 study, 167 postmenopausal women with newly diagnosed, operable, ER-positive, HER2-negative breast cancers were recruited. Participants were randomly allocated (2:1, favoring the combination) to two-weeks of preoperative treatment with anastrozole 1 mg once daily or the combination of anastrozole 1mg with pictilisib 260 mg once daily. The primary endpoint was inhibition of tumor cell proliferation, as measured by change in Ki-67 protein expression between tumor samples taken before and at the end of treatment. Secondary endpoints include induction of apoptosis (Caspase3) and safety. Comprehensive biomarkers analyses included targeted NGS of a comprehensive cancer panel of >400 genes (Ampliseq Comprehensive Cancer panel), copy number variation analyses, and pre- and post-treatment reverse-phase protein arrays (RPPA) and RNA profiling (NanoString nCounter platform).

Results:There was significantly greater geometric mean Ki67 suppression of 82.5% (90% CI, 78.3%-85.8%) for the combination vs 70.7% (61.0%-78.0%) for anastrozole [geometric mean ratio (combination/ anastrozole) 0.60 (0.58-0.85);p=0.01]. Higher baseline Ki67, Luminal B status and/or negative PR status were associated with increased benefit from adding pictilisib. A significant interaction was observed between PIK3CA mutation subtypes [helical domain mutations (HD), kinase domain mutations (KD), wildtype (WT)] and mean Ki67 suppression; the combination/anastrozole geometric mean ratio of Ki67 suppression was 0.48 (0.27-0.84; p=0.02) for patients with HD mutations and 0.63 (0.39–1.0; p=0.05) for patients with PIK3Ca WT, compared to 1.17 (0.57–2.41; p=0.64) for patients with KD mutations. This was largely due to patients with HD mutations showing a particularly poor response to anastrozole alone [mean Ki67 suppression 53.9% (9.5%-76.5%)], that was reversed by the addition of pictilisib [mean Ki-67 suppression 78.1% (71.0%-83.4%)]. On the other hand, patients with KD mutations responded well to anastrozole alone [mean Ki-67 suppression 77.7% (57.0%-88.4%)] and showed no benefit from the addition of pictilisib [mean Ki-67 suppression 73.9% (59.8%-83.0%)]. There was no significant difference in induction of apoptosis between treatment groups. Comprehensive pre- and post-treatment biomarkers analyses will be presented.

Conclusions: Adding pictilisib to anastrozole significantly increases the anti-proliferative response to preoperative treatment with anastrozole. A significant interaction was observed between PIK3CA mutation subtypes, with patients with helical domain mutations showing a particularly poor response to anastrozole alone that was reversed by the addition of pictilisib.

Citation Format: Schmid P, Pinder S, Wheatley D, Zummit C, Macaskill EJ, Hu J, Price R, Bundred N, Hadad S, Shia A, Sarker S-J, Lim L, Mousa K, O'Brien C, Wilson TR, Lackner MR, Gendreau S, Gazinska P, Korbie D, Trau M, Mainwaring P, Thompson A, Purushotham A. Interaction of PIK3CA mutation subclasses with response to preoperative treatment with the PI3K inhibitor pictilisib in patients with estrogen receptor-positive breast cancer [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 P2-08-02.

Abstract P1-11-05: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Watterson D, Purushotham A, Keeley V. Withdrawn [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 P1-11-05.

Abstract P3-03-42: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Purushotham A, Keeley V. Withdrawn [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 P3-03-42.

Abstract GS3-06: Dynamics of breast cancer relapse reveal molecularly defined late recurring ER-positive subgroups: Results from the METABRIC study

Background: Recent studies have demonstrated that women with early stage ER-positive (ER+) and HER2-negative (HER2-) breast cancer have a persistent risk of recurrence and cancer related death up to 20 years post diagnosis, highlighting the chronic nature of ER+ breast cancer and critical need to identify tumor characteristics that are more predictive of risk of recurrence than standard clinical covariates. However, progress in delineating the dynamics of breast cancer relapse and biomarkers of late recurrence has been hindered by the lack of large cohorts with long-term clinical follow-up and molecular information.

Methods: We report the results of a cohort of 3,240 breast cancer patients from the United Kingdom and Canada with 20 years of follow-up (median 9.75 years), including 1,980 with accompanying molecular data from the primary breast tumor. Information for each patient on loco-regional recurrence (LR), distant recurrence (DR), and site(s) of metastases was collected. We developed a non-homogenous Markov chain model that accounted for different clinical endpoints and timescales, as well as competing risks of mortality and the distinct baseline hazards that characterize different molecular subgroups. This approach enabled robust analysis of the spatio-temporal dynamics of breast cancer recurrence across the clinical subgroups, PAM50 subgroups and the integrative clusters, while also enabling individual risk of relapse predictions.

Results: We employed our multistate model to compute the probability of experiencing a LR or DR, as well as the baseline transition probabilities from surgery, LR or DR at various time intervals for average individuals in each of the clinical/molecular subgroups. These analyses reveal four late-recurring ER+ (predominantly HER2-) subgroups, together accounting for 26% of all ER+ tumors, with high (median 42-55%) risk of recurrence up to 20 years post-diagnosis. Each of these four subgroups maps to one of the Integrative Clusters, defined based on genomic copy number alterations and gene expression, and is enriched for a characteristic copy number amplification events: 11q13 (CCND1, RSF1), 8p12 (FGFR1, ZNF703), 17q23 (RPS6KB1) and 8q24 (MYC). These four molecular subgroups are superior in predicting late DR than standard clinical variables.

Conclusions: A detailed understanding of the rates and routes of metastasis and their variability across the distinct molecular subtypes is essential for devising personalized approaches to breast cancer care. We describe a molecularly characterized breast cancer cohort with long-term clinical follow-up and a statistical modeling framework, enabling delineation of the dynamics of breast cancer recurrence at unprecedented resolution. These analyses reveal four late recurring ER+ subgroups and accompanying biomarkers that collectively define the quarter of ER+ cases at highest risk of recurrence. Our findings highlight opportunities for improved patient stratification and biomarker-driven clinical trials directed at the subset of breast cancer patients with persistent risk of recurrence.

Citation Format: Curtis C, Rueda OM, Sammut S-J, Chin S-F, Caswell-Jin JL, Seoane JA, Callari M, Batra R, Pereira B, Bruna A, Ali HR, Provenzano E, Liu B, Parisien M, Gillett C, McKinney S, Green A, Murphy L, Purushotham A, Ellis I, Pharoah P, Rueda C, Aparicio S, Caldas C. Dynamics of breast cancer relapse reveal molecularly defined late recurring ER-positive subgroups: Results from the METABRIC study [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 GS3-06.

Abstract P2-07-01: Prediction model for lymphoedema, and effect of Lymphoedema diagnosis on quality of life (QoL) and distant recurrence from breast cancer

Introduction

Lymphoedema develops after surgery in 30% patients. In a prospective, multi-centre UK study, we used a validated perometer arm measurement to determine 1) the factors predicting lymphoedema development and 2) the effect of a lymphoedema diagnosis on QoL and survival.

Methods

Participants (n = 1100) undergoing axillary clearance at 9 centres underwent arm volume measurements pre and post-surgery by perometry, and completed FACT-B+4 and Lymphoedema checklist questionnaires. Relative arm volume increase (RAVI) of >10% diagnosed lymphoedema. Predictors of lymphoedema development were determined using logistic regression, and changes in QoL were assessed using Generalised Estimating Equation (GEE) analyses.

Results

Median patient age was 56 (range 22 to 90) years; 78% received radiotherapy and 65% chemotherapy. Lymphoedema was detected in 21.4% of women by perometry and 24.4% underwent sleeve application by 24 months.

Initial decreases in QoL scores post-surgery were greater in patients with lymphoedema and took longer to return to baseline values (FACT-B p=0.014, TOI p=0.008, ARM subscale p<0.001).

RAVI at 1 month (p<0.001), BMI in three categories (≤25, >25-≤30 and >30, p=0.05), ER status (p=0.05) and number of positive nodes (p<0.001) were used to develop a novel scoring model (AUROC 0.80) to predict lymphoedema. Out of 826 patients used for the model, 75% of patients had low scores (≤1) at 1 month and 11.6% developed lymphoedema by 24 months, whereas 20% who scored moderate risk (1.5-2) had a 31.3% risk and 5% who scored high risk (2.5-4) and had a 66.7% risk. Using the model scores, 75% of patients could be reassured regarding their lymphoedema risk.

Local recurrence was 1.7%. One hundred and twenty-nine patients had died of breast cancer (n=88) or had distant recurrence (n=41) across the study.

Lymphoedema (RAVI≥10%) by 9 months was an independent predictor of post 9 months distant disease-free cancer survival (Table).

Distant Disease Free Survival (DDFS) after Lymphoedema diagnosis Single variableMultivariableVariable (between 3 and 9 months)nHazard ratio (HR) (95% CI)p-valueHR (95% CI)p-valueRAVI ≥ 10% Yes: 105 vs No9552.30 (1.39-3.81)0.0011.73 (1.01-2.96)0.047ER Status Negative: 1719532.94 (1.92-4.49)<0.0011.734 (1.06-2.83)0.028No. positive nodes*9691.07 (1.05-1.09)<0.0011.05 (1.03-1.08)<0.001Adjuvant CT Yes: 654 vs No9630.83 (0.54-1.27)0.390.60 (0.37-0.964)0.035Hormone treatment Yes: 808 vs No9640.45 (0.28-0.72)0.001--Tumour size*9591.02 (1.01-1.024)<0.0011.02 (1.01-1.03)<0.001Grade     0/1: 679611 (-)<0.0011 (-)<0.0012: 428 3.96 (0.54-29.324) 2.69 (0.36-20.33) 3: 436 11.59 (1.61-83.54) 6.91 (0.94-50.90) Undiff: 30 17.58 (2.12-146.184) 12.54 (1.43-109.96) *Per unit increase

Conclusions

Lymphoedema is associated with lasting quality of life deficits and early distant relapse.

Women at low risk of lymphoedema (75%) can be reassured using the scoring model. Early Arm measurements at 1 month post-surgery a useful measurement time to determine lymphoedema risk and enable patients to be reassured (75%) or plan for lymphoedema monitoring.

Citation Format: Bundred NJ, Foden P, Riches K, Morris J, Evans A, Todd C, Bramley M, Skene A, Purushotham A, Keeley V. Prediction model for lymphoedema, and effect of Lymphoedema diagnosis on quality of life (QoL) and distant recurrence from breast cancer [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 P2-07-01.

Abstract PD4-02: A study to determine the optimal method of detection and threshold for lymphoedema intervention: A multi-centre prospective study

Introduction

Lymphoedema, a complication of nodal surgery in 30-40% of patients, reduces quality of life for sufferers. This prospective, multi-centre study compared multi-frequency bioimpedance spectroscopy (BIS, ImpediMed) with a validated perometer method to determine which test is more sensitive for detecting lymphoedema after axillary clearance and identify the factors predicting lymphoedema development.

Material and methods

Participants (n = 629) undergoing axillary clearance at 9 UK centres underwent pre-operative and arm volume measurements post-surgery (1, 3, 6, 9 & 12 months, then 6 monthly) by arm perometry, BIS measurements (L-Dex) and recorded self-reported symptoms via questionnaires. Follow-up was a minimum of two years from surgery. Change in arm volume was calculated using relative arm volume change (RAVC) with >10% increase defined as lymphoedema. The predictors of lymphoedema development and optimal method for its detection were assessed using Cox Regression, Log Rank and Kaplan-Meier survival analyses.

Results

In total, 629 women underwent axillary surgery, with a median age of 56 (range 22 to 90) years; 80% were ER positive and received endocrine therapy, 78% received radiotherapy and 65% received chemotherapy. Lymphoedema was detected by 24 months in 124 (20%) women by perometry. Using the LDex >10 cut-off score, bioimpedance sensitivity was 71% and specificity was 89% (PPV 47%) compared to RAVC changes. Women who had an RAVC >5%-<10% at six months developed lymphoedema in 44% of cases by two years, whereas those who had less than 3% RAVC developed lymphoedema in 9% of cases (p=>0.000001). Twenty-six per cent of ER negative patients developed lymphoedema compared to 19% ER positive cancer patients.

The type (taxane versus no taxane) and whether chemotherapy was neo-adjuvant or adjuvant did not predict lymphoedema development.

Univariate analysis revealed BMI (p=0.003), ER negativity (p=<0.010), absence of endocrine therapy (p=0.034), number of nodes involved (p=0.001) and an increase in RAVC >5%-<10% (p<0.005) all predicted lymphoedema development by two years. On multivariate analysis, RAVC >5%-<10% after six months (HR 5.51 95% CI 3.05 – 9.94) along with number of nodes involved (HR 1.06 95% CI 1.03 – 1.09) and BMI HR 1.04 (1.04 – 1.09) were included in the model for predicting lymphoedema development at two years.

Conclusions

This is the first report; ER negative cancer is associated with an increased risk of lymphoedema after axillary node clearance. Arm measurements should be taken from baseline in all patients undergoing axillary surgery and increases greater than 3% should lead to further surveillance to prevent lymphoedema development. Perometer measurement is the optimal technique for measuring and predicting the development of lymphoedema.

A threshold RAVC of >5%-<10% after six months predicts lymphoedema in 44% of patients by two years.

(Funded by NIHR Programme Grant).

Citation Format: Bundred NJ, Ashton S, Riches K, Ashcroft L, Evans A, Todd C, Bramley M, Hodgkiss T, Purushotham A, Keeley V. A study to determine the optimal method of detection and threshold for lymphoedema intervention: A multi-centre prospective study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD4-02.

Cerenkov luminescence imaging (CLI) for image-guided cancer surgery

Cerenkov luminescence imaging (CLI) is a novel molecular optical imaging technique based on the detection of optical Cerenkov photons emitted by positron emission tomography (PET) imaging agents. The ability to use clinically approved tumour-targeted tracers in combination with small-sized imaging equipment makes CLI a particularly interesting technique for image-guided cancer surgery. The past few years have witnessed a rapid increase in proof-of-concept preclinical studies in this field, and several clinical trials are currently underway. This article provides an overview of the basic principles of Cerenkov radiation and outlines the challenges of CLI-guided surgery for clinical use. The preclinical and clinical trial literature is examined including applications focussed on image-guided lymph node detection and Cerenkov luminescence endoscopy, and the ongoing clinical studies and technological developments are highlighted. By intraoperatively guiding the oncosurgeon towards more accurate and complete resections, CLI has the potential to transform current surgical practice, and improve oncological and cosmetic outcomes for patients.

Abstract P5-13-01: Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study)

Background: The OPPORTUNE Study randomized postmenopausal patients (pts) to receive 2-week preoperative treatment with anastrozole (ANA) plus pictilisib ("ANA+PIC" arm) or ANA alone. Patients had newly diagnosed, operable, ER+, HER2- invasive breast cancer of ≥1 cm size. The primary outcome at interim analysis (n=70) revealed that the addition of PIC significantly increased the anti-proliferative response to ANA as measured by reduction in Ki67 immunohistochemistry (IHC). Multivariate analyses suggested benefit of PIC for patients with luminal B disease (Schmid et al. SABCS 2014).

Methods: RNA expression analysis of ∼800 breast cancer-related genes was performed on patients analyzed at the interim analysis, including 14 (ANA) and 20 (ANA+PIC) patients with matched pre- and post- treatment paired tumour samples using the nCounter platform (NanoString). Differential expression of individual genes by arm was assessed using paired and moderated t-tests and statistical significance assessed through false discovery rate (FDR). Ingenuity Pathway Analysis (IPA) of differentially expressed transcripts identified pathways of relevance. Protein expression was analyzed by reverse protein array ( RPPA) in pre- and post-treatment samples.

Results: In an unsupervised analysis, down-regulation of genes associated with ER signaling was observed in patients who received single-agent ANA and ANA+PIC, which included genes that regulate the cell cycle, cell death, survival, growth and proliferation and known ER target genes (e.g., PGR, GREB1). In addition, transcripts related to growth factor signaling pathway appeared to be specifically modulated in the ANA+PIC arm, possibly via the upregulation of the expression of RTK ligands. There were no clear changes in PI3K-related phosphoproteins (e.g., AKT, S6, 4E-BP1) in the post-treatment samples by RPPA. However, known PI3K-regulated genes, IRS2 and PIK3IP1, were upregulated in the post-treatment samples and a composite PI3K gene expression signature score (O'Brien et al. 2010) was reduced in both study arms following treatment. This PI3K signature was associated with pre-treatment luminal B status (n=27) and, consistent with this finding, the baseline PI3K gene signature score in the ANA arm, but not the ANA+PIC arm, was inversely associated with the decrease in post treatment Ki67. The tumor immune microenvironment was analyzed though the use of composite gene sets. In our initial observations, analysis of pre- and post-treatment samples showed that 2-week treatment with ANA resulted in a modest increase in transcripts associated with multiple immune signatures, which was further enhanced by the addition of PIC.

Conclusions: Gene expression analysis of pre- and post-treatment samples in the OPPORTUNE study demonstrates on-target inhibition of ER and PI3K signaling networks. The analysis of additional paired samples is in progress to further assess if 2-weeks of treatment with a regimen containing an AI in patients with early breast cancer impacts the tumor immune microenvironment.

Citation Format: Schmid P, Pinder SE, Bundred N, Wheatley D, Macaskill J, Zammit C, Hu J, Price R, Shia A, Lim L, Parker P, Molinero L, Yu J, O'Brien C, Wilson T, Savage H, Derynck M, Lackner MR, Amler L, Purushotham A, Thompson A, Gendreau S. Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-01.

The prevalence of lymphoedema in women who attended an information and exercise class to reduce the risk of breast cancer-related upper limb lymphoedema

Breast cancer-related upper limb lymphoedema (BCRL) affects approximately 20 % of women undergoing axillary intervention. Women who attended a “reducing your risk of lymphoedema” class, including exercise instruction, anecdotally reported positive BCRL outcomes. The aim of this study was to examine BCRL outcomes and perceived benefit for attendees at a “reducing your risk of lymphoedema” class between 2000 and 2005. A cross-sectional study was conducted in two parts: (1) self-report questionnaire regarding lymphoedema status and benefit received from class and exercise programme; (2) clinical evaluation and objective measurement to confirm BCRL. 46 women completed questionnaires; 40 continued to clinical evaluation and objective measurement. BCRL prevalence defined as ≥10 % excess limb volume was only 5 %, although clinician judgement identified 23 % with arm lymphoedema and 8 % with lymphoedema limited to the hand. Clinician judgement correlated highly with patient self-report (Kappa = 0.833, p = 0.000). All women found the class beneficial, reporting increased confidence to return to normal life and a wide range of activities/exercise. We conclude that prevalence of BCRL should be determined by both clinical judgement and objective measurement to avoid underestimation. The benefit of group education with a lymphoedema expert and of exercise instruction should be further explored, and the potential for exercise to reduce BCRL prevalence should be examined.

Age at diagnosis and distant metastasis in breast cancer--a surprising inverse relationship

INTRODUCTION

Predictors for site of distant metastasis and impact on survival in breast cancer are incompletely understood.

METHODS

Clinico-pathological risk factors for site of distant metastasis and survival were analysed in patients with invasive breast cancer treated between 1986 and 2006.

RESULTS

Of 3553 patients, with median follow-up 6.32years, 825 (23%) developed distant metastasis. The site of metastasis was bone in 196/825 (24%), viscera in 540/825 (65%) and unknown in 89 (11%). Larger primary invasive tumour size, higher tumour grade and axillary nodal positivity increased risk of metastasis to all sites. Lobular carcinoma was more likely to first metastasise to bone compared to invasive ductal carcinoma (NST). Oestrogen receptor (ER) negative, progesterone receptor (PgR) negative and/or Human epidermal growth factor (HER2) positive tumours were more likely to metastasise to viscera. A striking relationship between increasing age at diagnosis and a reduction in risk of distant metastasis to bone and viscera was observed. Median time to death from onset of metastatic disease was 1.52 (Interquartile range (IQR) 0.7-2.9)years for patients with bone metastasis and 0.7 (IQR 0.2-1.5)years for visceral metastasis. On multivariate analysis, despite the decrease in risk of distant metastasis with increasing age, there was an elevated hazard for death in patients >50years at diagnosis of metastasis if they developed bone metastasis, with a similar trend observed in the >70years age group if they developed visceral metastasis.

CONCLUSION

These findings indicate that there are biological mechanisms underlying the impact of age on the development of distant metastasis and subsequent death. This may have important implications in the treatment of breast cancer.

Abstract P3-09-09: Comparison of multi-frequency bioimpedance with perometry for the early detection of lymphoedema after axillary node clearance

Introduction

Women who undergo axillary clearance are at risk of developing lymphoedema. Early detection is recommended by arm volume measurements from a baseline before surgery but the optimal test is unclear. This prospective multi-centre study compares multi-frequency bioimpedance spectroscopy (BIS, ImpediMed) with the validated perometer method to determine which test is more sensitive for detecting lymphoedema within 24 months of surgery. Results from 441 women with up to six months follow-up are reported here to determine whether the timing of arm measurement affects results.

Methods

Participants (N = 441) undergoing Axillary Clearance underwent pre-operative and subsequent regular measurements post-surgery (1, 3, 6, 9 & 12 months, then 6 monthly), of arm volume by perometry and BIS measurements as well as self-reported symptoms of swelling, numbness or heaviness. The primary endpoint of lymphoedema was defined as ≥10% increase in volume compared to the contralateral arm by perometry.

Results

We report the data from 441 patients with 6 month follow-up data, their median age is 55 years ranging from 27 to 90 years. Eighty percent of patients were ER positive and received endocrine therapy as well as surgery. Eighty percent also underwent radiotherapy to the breast or chest wall, while 70% received chemotherapy in addition to surgery. Mean percentage increase in arm volume by perometry at 6 months was 2.03% with a moderate correlation between perometry and BIS at 3 months (r = 0.38) and 6 months (r = 0.37). In 441 patients with 6 months follow-up, the gold standard perometry detected lymphoedema in 44 (10%) patients by 6 months compared to the contralateral arm, whereas BIS measured using the unit L-Dex was positive (showed an increase of an L-Dex of 10) in 103 (21%) patients. Of the 99 patients with 18 months follow-up, 24% have lymphoedema as detected by perometry. When compared with the baseline measurements for perometry and BIS, the month 1 measurements detected fewer cases of lymphoedema by 6 months, 11 (42%) fewer for perometry and 18 (30%) fewer for BIS. 25% of patients reported symptoms before surgery. While 100% of those with lymphoedema at 6 months post-surgery reported symptoms, 23% with no lymphoedema also reported at least one symptom at 6 months.

Conclusions

Pre-operative measurements should be used as baseline to enable accurate monitoring of lymphoedema development. Symptoms alone are not an accurate predictor of current or future lymphoedema and arm sleeves should not be prescribed for symptoms without measuring arm volume change compared to the contralateral arm. The modest correlation between perometry and BIS at 6 months suggests arm volume measurements remain necessary before and after ANC for monitoring, although longer term follow-up data is required to determine the most sensitive method of predicting lymphoedema.(Funded by NIHR Programme Grant).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-09.

Abstract P2-10-29: Time dependent breast cancer metastasis prediction using novel biological imaging, clinico-pathological and genomic data combined with Bayesian modeling to reduce over-fitting and improve on inter-cohort reproducibility

Background: Breast cancer heterogeneity demands that prognostic models must be biologically driven and recent clinical evidence indicates that future prognostic signatures need evaluation in the context of early versus late metastatic risk prediction. The aim of our work was to identify biologically validated quantitative imaging parameters with improved correlation to clinical outcome, and to address some of the remaining obstacles for a truly robust prognostic model in clinical use.

Method: We identified 4 seed proteins (ezrin/radixin/moesin-cofilin), along with several kinases as biologically relevant subnetwork of proteins that control tumor cell motility and metastasis. Patient-derived breast cancer tumour samples were used to perform a combination of imaging methods such as Fluoresecence lifetime imaging microscopy, automated segmentation and co-localisation intensity analysis. A complexity optimized Bayesian proportional hazard regression model was performed on a total of 419 breast cancer patients to validate time dependent predictions using traditional clinicopathological, genomic and our novel optical imaging-derived parameters. An independent dataset of 300 patient samples from the Leeds Institute of Molecular Medicine is currently being evaluated, representing a large cross centre validation of our integrated model.

Results: We demonstrate that the traditional gold standard clinico-pathological variables are poor predictors for patients that survive long periods, and that their predictive significance (in terms of hazard ratios) varies significantly between two temporal cohorts where the adjuvant treatments are vastly different. Moreover, we investigate the predictive accuracy of a combined imaging/clinicopathological model compared with genomic/clinicopathological models. We demonstrate how to reduce over-fitting to help improve the performance of prognostic models. Results of an integrated model combining genomic and imaging parameters are still awaited.

Discussion: We have produced the first optical imaging-derived multivariate tumour metastatic signature, which measures underlying key biological variables involved in regulating cancer cell motility. Using Bayesian proportional hazards regression in a time-dependent manner, we highlight the inadequacies of existing prediction tools and present a model combining the clinicopathological parameters with our imaging-based metastatic signature, as an integrative reproducible prognostic tool across different temporal cohorts.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-10-29.

P2-08-07: Ex-Vivo High Resolution MRI of Sentinel Lymph Nodes Following Subcutaneous Injection of Superparamagnetic Iron Oxide Nanoparticles

Background: Superparamagnetic iron oxide (SPIO) enhanced axillary MRI is a promising novel imaging modality that could be used to characterize sentinel nodes non-invasively. In order to better characterize lymph nodes and evaluate their morphological features, we imaged nodes ex-vivo using high resolution MRI, following a pre-operative subcutaneous injection of SPIO.

Material and methods: Prior to surgery patients received a circumareolar injection of SPIO (Endorem, Guerbet, Paris) into the upper outer quadrant of the affected breast. Sentinel lymph nodes excised during surgery were transported to the imaging department fresh. Nodes were placed in glass tubes and scanned using a Bruker 9.4T MRI system (T2 mapping: turbo spin echo, 16 equi-spaced TEs from 7.1 to 113.6 ms, TR = 1616 ms. T2* mapping: gradient echo, 6 equi-spaced TEs from 3.5 to 21 ms, TR = 1000 ms, flip angle = 30 degrees. Diffusion-weighted: spin echo, b-values 0 and 1000 s/mm2, TE = 18 ms, TR = 6500 ms.). Slice thickness was 1 mm with an in plane spatial resolution of 100μm. Image analysis was undertaken using Osirix (v3.8, 64-bit).

Results: A total of 40 nodes were successfully imaged, excised from 14 patients. The internal architecture of nodes was clearly seen and in the 3 involved nodes, a macrometastasis was identified. Three patients received a 4ml injection of SPIO and 11 patients, a 2ml injection. More SPIO deposition was seen within nodal sinuses following 4ml of SPIO, but there was no significant decrease in mean T2 value. Four nodes were re-imaged following formalin fixation and nodal architecture was unchanged with a trend towards an increase in mean T2 values within nodes. SPIO was identified in all sentinel nodes.

Discussion: Ex-vivo MRI with subcutaneous SPIO contrast, is a useful method for imaging and characterization of sentinel nodes. A better understanding of ex-vivo features is a useful aide to understanding the morphological features seen following in-vivo SPIO enhanced axillary MRI.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-07.

Abstract P4-09-13: Predicting Potential Patterns of Metastatic Spread and Outcomes in Breast Cancer

Background: Metastasis progression in breast cancer can be viewed as a stepwise sequence of events that occurs with distinct temporal patterns and in unique organ sites. Our previous results indicate that metastatic spread occurs along distinct pathways governed by biological characteristics of the primary tumour.

Aim: To examine clinical and histopathological factors that predict for patterns of metastatic spread and survival in breast cancer. Materials and Methods: A study population consisting of 5569 patients diagnosed with breast cancer between 1975 and 2006 was studied. Median follow-up was 7.7 years, interquartile range (IQR) 3.4-14.3 years. The median metastasis-free interval was 6.7 years, IQR 2.6-14.6 years. Survival analysis was performed using Kaplan-Meier method and group comparisons made with a log-rank test. Both univariate and stepwise Cox proportional hazard models were used to investigate the relationship between prognostic factors and breast cancer survival. Results: Of 5569 patients, 1718 (31%) developed distant metastasis; 499 (29%) to bone, 990 (58%) to other organs and 229 (13%) to bone followed by a second metastatic event in another organ site within 6 months after the first event (bone + 2nd site).

Patterns of metastatic spread: In univariate analysis, ER-ve tumours were 45% more likely to spread to other organs or to bone + 2nd site. Grade 3 cancers, compared with grade 1 tumours, had a 2-fold increase in the likelihood of metastasising to bone only, 4-fold to bone + 2nd site and 7.5-fold to other organs. In multivariate analysis, node positivity, higher grade and larger tumour size predicted for metastasis to bone or any other organ site whilst node positivity and ER negativity predicted for metastasis to bone + 2nd site. Patients >70 years were 60% less likely to have bone metastasis compared with patients <50 years. ER+ve tumours did not show an increased predilection to bone metastasis on multivariate analysis. Survival from 1st onset of metastasis (breast cancer-related deaths): The median survival in months [95% CI] for patients who developed bone metastasis was 24 [21,26], bone + 2nd site 12 [9, 13] and other organ sites 14 [13, 16] months, respectively. There was a highly significant exponential decrease in survival with increasing age (P<0.02). This effect was even more pronounced in those patients >70 years age who developed bone + 2nd site metastasis (5 times greater hazard of dying compared with <50 years), and was further amplified in grade 3 tumours in this group of patients. Furthermore, node positivity and grade 3 tumours had the maximum negative effect on survival in this group compared with patients who had metastasised to bone only or to other organ sites. Conclusion: The clinical and histopathological factors that predict for patterns of metastatic spread and survival in breast cancer in this large cohort support some previous observations, refute others and demonstrate new findings. These observations merit further investigation and, potentially, future trials of adjuvant therapy that are designed according to predictive patterns of metastatic spread.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-09-13.

Abstract P5-01-11: Monitoring Primary Medical Therapy with Three-Dimensional Optical Mammography

Background: Optical tomography is a functional imaging technique using near-infrared (NIR) light to produce three-dimensional (3D) breast images of tissue oxygen saturation and haemoglobin concentration. The advantages include the lack of ionising radiation and the quantative physiological information obtained. With increasing use of primary medical therapy, there is a need for a non-invasive functional imaging tool to evaluate response to treatment. Optical tomography was evaluated for monitoring early response to treatment.

Materials and Methods: Women with newly diagnosed breast cancer, suitable for primary medical therapy, were recruited. Changes in physiological and optical properties within the tumour were evaluated during the course of neoadjuvant chemotherapy or endocrine therapy. For patient undergoing neoadjuvant chemotherapy, optical imaging wasperformed prior to treatment, at 2 week, halfway through and on completion of chemotherapy. Images of light absorption and scatter, haemoglobin concentration ([HbT]) and oxygenation (SO2) are produced. Results: To date, ten women have been recruited to the project, and are being scanned throughout the course of their treatment. Five women are undergoing neoadjuvant chemotherapy and five are undergoing endocrine treatment prior to surgery. Nine women have been scanned more than once with five women scanned three times, and one has completed the protocol. The contrast between the tumour and the background tissue was calculated and any changes in ROI contrast and physiological parameters tracked. Initial scans show an increase in [HbT] and a decrease in SO2 in the region of the tumour. Changes in contrast and [HbT] in the tumour ROI can be seen early in treatment. A 45 year old patient was being treated with neoadjuvant taxane chemotherapy for a 26x21x34 mm Grade 2 carcinoma. The tumour [HbT] was 43.95±4.20 μM prior to treatment, falling to 25.6±6.43 μM by Week 9 and 19.19±0.36 μM by Week 18 of treatment and 23.5871± 1.6616 at the final scan. Background tissue [HbT] remained constant at ∼21±4 μM. Biopsy results classified the patient as a good responder to treatment. Initial data from other patients show changes in [HbT] at the two week scan, some showing a decrease and others show an increase in measured [HbT]. Future work will include correlation of optical data with clinical MRI findings, biopsy results and clinical outcome. Discussion: Optical imaging of the breast is feasible during primary medical therapy and can be used to assess response to treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-01-11.

Regulation of adipose triglyceride lipase by rosiglitazone

AIM

To elucidate the mechanism by which rosiglitazone regulates adipose triglyceride lipase (ATGL).

METHODS

Male C57Bl/6 mice were treated with rosiglitazone daily (10 mg/kg body weight), and adipose tissues were weighed and preserved for mRNA and protein analysis of ATGL. In parallel, preadipocyte (3T3-L1) cells were differentiated with insulin/dexamethasone/3-isobutyl-1-methlxanthine cocktail or rosiglitazone, and ATGL levels were measured with real-time PCR, western blotting and immunohistochemistry.

RESULTS

Rosiglitazone concomitantly promoted differentiation of pre-adipocytes to functional adipocytes and induced mRNA levels of ATGL. The peroxisome proliferator-activated receptor-gamma (PPARgamma) antagonist bisphenol A diglycidyl ether significantly abrogated the induction of mRNA, but not protein levels of ATGL by rosiglitazone in differentiated 3T3-L1 adipocytes. In the presence of epinephrine rosiglitazone stimulated free fatty acid release and increased diacylglycerol acyltransferase-1 (DGAT-1) mRNA suggest that ATGL and DGAT-1 may be cooperatively involved in rosiglitazone-stimulated triglyceride hydrolysis and fatty acid re-esterification in 3T3-L1 adipocytes. Treatment of 3T3-L1 adipocytes with rosiglitazone or insulin did not appear to alter localization of ATGL staining surrounding lipid droplets. Finally, we found that rosiglitazone increased ATGL mRNA levels in 3T3-L1 adipocytes in the presence of cycloheximide, an inhibitor of protein synthesis, suggesting that rosiglitazone regulation of ATGL occurs at the transcriptional level.

CONCLUSIONS

Rosiglitazone directly regulates transcription of ATGL, likely through a PPARgamma-mediated mechanism.

Evidence-based guidelines and decision support services: A discussion and evaluation in triple assessment of suspected breast cancer

Widespread health service goals to improve consistency and safety in patient care have prompted considerable investment in the development of evidence-based clinical guidelines. Computerised decision support (CDS) systems have been proposed as a means to implement guidelines in practice. This paper discusses the general concept in oncology and presents an evaluation of a CDS system to support triple assessment (TA) in breast cancer care. Balanced-block crossover experiment and questionnaire study. One stop clinic for symptomatic breast patients. Twenty-four practising breast clinicians from United Kingdom National Health Service hospitals. A web-based CDS system. Clinicians made significantly more deviations from guideline recommendations without decision support (60 out of 120 errors without CDS; 16 out of 120 errors with CDS, P<0.001). Ignoring minor deviations, 16 potentially critical errors arose in the no-decision-support arm of the trial compared with just one (P=0.001) when decision support was available. Opinions of participating clinicians towards the CDS tool became more positive after they had used it (P<0.025). The use of decision support capabilities in TA may yield significant measurable benefits for quality and safety of patient care. This is an important option for improving compliance with evidence-based practice guidelines.

Neural correlates of encoding and expression in implicit sequence learning

In the domain of motor learning it has been difficult to separate the neural substrate of encoding from that of change in performance. Consequently, it has not been clear whether motor effector areas participate in learning or merely modulate changes in performance. Here, using a variant of the serial reaction time task that dissociated these two factors, we report that encoding during procedural motor learning does engage cortical motor areas and can be characterized by distinct early and late encoding phases. The highest correlation between activation and subsequent changes in motor performance was seen in the motor cortex during early encoding, and in the basal ganglia during the late encoding phase. Our results show that rapid encoding during procedural motor learning involves several distinct processes, and is represented primarily within motor system structures.

Cerebellum activation associated with performance change but not motor learning

The issue of whether the cerebellum contributes to motor skill learning is controversial, principally because of the difficulty of separating the effects of motor learning from changes in performance. We performed a functional magnetic resonance imaging investigation during an implicit, motor sequence-learning task that was designed to separate these two processes. During the sequence-encoding phase, human participants performed a concurrent distractor task that served to suppress the performance changes associated with learning. Upon removal of the distractor, participants showed evidence of having learned. No cerebellar activation was associated with the learning phase, despite extensive involvement of other cortical and subcortical regions. There was, however, significant cerebellar activation during the expression of learning; thus, the cerebellum does not contribute to learning of the motor skill itself but is engaged primarily in the modification of performance.