Abstract P5-15-04: Oncotype DX cost effectivity to a Brazilian public hospital

Introduction: The Oncotype DX was associated to 14% of adjuvant chemotherapy administration to Hormonal Receptor positive (HR+) and HER2 negative, T1N0 or T2N0 breast cancer patients at Tailor X trial recently published (RS>25)

Objective: To describe the adjuvant chemotherapy administration to a Brazilian public hospital for HR+ HER2 negative, T1N0 or T2N0 breast cancer patients. And the estimate the cost effectivity of Oncotype DX in our low income scenary.

Materials and Methods:This retrospective cross-sectional study was conducted at the Oncology Division of the Women's Hospital - CAISM of the State University of Campinas (UNICAMP), Brazil. All patient data were found from the hospital records from 2007 to 2009. It was included T1N0 and T2N0 HR+/HER2 negative breast cancer patients. Patients submitted to neoadjuvant treatment were excluded.

We calculate the final cost of different types of chemotherapy used and the potential impact to oncotype DX introduction in this scenary.

Results: It was found 109 patients records. 66% (72/109) had received adjuvant chemotherapy. 35% (38/109) had AC (X6), 29% (32/109) had CMF (X6) and 2% (2/109) had AC-T (X4). The total cost for chemotherapy scheme were; AC (X6) US$ 346,9; CMF (X6), US$300,6; ACT (X4), US$395,9. The total cost of chemotherapy was US$ 23.596,83 to 72 patients. If we consider 14% (15/109) of adjuvant chemotherapy associate to a Oncotype DX use (Tailor X RS>25), It would reduce adjuvant chemotherapy administration to 15 patients. The chemotherapy cost would be US$ 4588,27. In our scenary, It could save US$ 19.008,56. Nevertheless, the Oncotype Dx cost to Brasil is US$ 3.200,00 for each test. To 109 patients the total cost would be (109 X US$ 3.200,00) US$ 348.800,00. Therefore, the total cost for Oncotype DX program plus adjuvant chemotherapy for our patients would be US$ 348.800,00 + US$ 4.588,27= US$ 353.388,27. While in the real situation we had spent US$ 23.596,83. The total estimate cost would be 15 times more.

Conclusion: At the moment, because of the assay high cost and the low cost of the adjuvant chemotherapy to HR+, HER2 negative T1N0 and T2N0, It would be difficult to consider Oncotype DX cost-effective to Brazilian public heath system. Even considering many advantages to spare chemotherapy to this population.

Citation Format: Cabello C, de Andrade RN, Cabello TF, Teixeira S, da Costa LS, Ramalho S. Oncotype DX cost effectivity to a Brazilian public hospital [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 P5-15-04.

[Consensus on acute ischemic stroke]

Stroke is the third cause of death and the first cause of disability in Argentina. Ischemic events constitute 80% of cases. It requires the implementation of systematized protocols that allow reducing the time of care, morbidity and mortality. Specialists from nine medical societies related to the care of patients with cerebrovascular disease participated in the consensus. A separate agenda was agreed upon in chapters and for the writing of them, work groups were formed with members of different medical specialties. The level of recommendation was discussed and agreed upon for each topic based on the best clinical evidence available for each of them. An adaptation to the local scope of the recommendations was made when it was considered necessary.The American Heart Association system was used to draft the recommendations and their level of evidence. The correction and editing were done by five external reviewers, who did not participate in the writing and with extensive experience in vascular pathology. Once the preliminary document was finalized, a general meeting was held with all the members of the working groups and the reviewers to reach final recommendations. The consensus covers the management of ischemic stroke in the pre-hospital phase, initial evaluation in the emergency center, recanalization therapies (thrombolysis and/ or mechanical thrombectomy), decompressive craniectomy, neuroimaging and clinical care in the hospital.

Abstract P4-02-09: Breast cancer and magnetic resonance imaging (MRI): Background parenchymal enhancement (BPE) predicting response to neoadjuvant chemotherapy (NAC)

Objective: To assess the association of MRI BPE and pathological response in women diagnosed with stage II/III breast cancer submitted to NAC. Methods: This observational and cross-sectional retrospective study was performed in consecutive women who underwent NAC and had MRI exams before and after chemotherapy. The MRI was done before and after 2 weeks of completing NAC. BPE was classified according to ACR-BIRADS 5th edition. The type of BPE before NAC, its changes and the relationship to total pathologic complete response (TpCR) were evaluated. Data were paired with patient age, size on MRI before and after NAC, features of clinical response according to the RECIST criteria, tumor grade and immunohistochemical (IHC) subtypes. MRI assessment included amount of fibroglandular tissue, symmetry of BPE and measurement of tumor at the longest diameter. All images were blinded reviewed by a radiologist. We used for the changes of the BPE the Bowker symmetry test or the McNemar test and to analyze the factors related to the clinical and pathologic responses, logistic regression analysis. The level of significance adopted was 5% (p<0.05). Results: We studied 71 women between 2009 and 2016. The medium age was 37 years old. BPE was symmetrical in 68 women (95.8%). Moderate and marked BPE was present in 28 (39.4%) of the affected breasts and in 25 (34.2%) of the contralateral breasts. After NAC all BPE were symmetrical and just 3% of them were moderate or marked. Regarding the IHC subtype, 40 women (56.3%) were triple negative or HER2 positive, and these women had a higher frequency of TpCR (55% for each, compared to 12.9% in patients with luminal subtypes). We found to be independently associated with pCR: the reduction of BPE (in the affected or contralateral breast) and the molecular subtypes triple negative and HER2 positive

Table 1. Multivariate Analysis related to TpCR (n=71).VariableCategoryP-ValueO.R.*CI 95% O.R.*Tumor Size on MR pre-MAC (cm) 0.1710,8590.691-1.068Luminal subtypeLuminal B (ref.)---1.00--- Luminal A0.3120.450.10-2.11 HER2pos/ Luminal B HER20.0055.781.71-19.58 Triple negative0.0493.271.01-10.64Age (years) 0.3870.9820.942-1.023Nottingham grade1 (ref.)---1.00--- 20.0817.830.78-79.16 30.0967.100.71-71.31BPE pre-NAC (S or A)Asymmetric (ref.)---1.00--- Symmetric0.3273.030.33-27.76BPE pre-NAC affected breastMinimal (ref.)---1.00--- Mild0.8120.860.24-3.09 Moderate0.3711.890.47-7.64 Marked0.5911.570.30-8.17BPE pre-NAC contralateral breastMinimal (ref.)---1.00--- Mild0.7130.790.22-2.81 Moderate0.2502.330.55-9.77 Marked0.4701.880.34-10.43BPE ChangeSame/increased (ref.)---1.00--- Reduction0.0263.011.14-7.96* OR (Odds Ratio) = Risk ratio to pCR; (n=26 pCR, n=7 DpCR, n=31 PR e n=7 ED, where Total pCR is pathological complete response (without invasive and DCIS in the breast and axilla) DpCR is pathological response with just DCIS, PR is partial response and ED is stable disease – we haven't progression disease). CI 95% OR = Confidence interval of 95% to risk ratio. Ref.: reference level. Proportional risk models.

Conclusion: BPE reduction was significantly associated with TpCR. Nevertheless, patterns of BPE pre-NAC have no association with pathological response.

Citation Format: Teixeira SRC, Camargo HSAd, Ramalho S, Natal R, Machado HdC, Camargo MMAd, Azevedo J, Arruda MdS, Negrão EMS, Almeida NR, Teixeira AL, Cabello V, Cabello C. Breast cancer and magnetic resonance imaging (MRI): Background parenchymal enhancement (BPE) predicting response to neoadjuvant chemotherapy (NAC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-02-09.

Abstract P4-10-15: Impact of delay in breast cancer diagnosis and treatment according to health insurance status in southwest Brazil and Houston, Texas

Background: Access to medical care vary across the world and is related to different health systems with an impact in recurrence.Objective: To evaluate disparities in breast cancer(BC) diagnosis and treatment between public and private services in southwest Brazil and at two public safety net hospitals in Houston, Texas.Methods: Women diagnosed with BC stages I-III between 2009 to 2011, and treated at the four hospitals in Brazil and two health centers in US were included. All statistical analyses were performed in R studio software, and p<0.05 was considered significant.Results: 1245 women were included: 967 from public health system (PHS) (20.3% from Houston, Texas) and 274 from private system(PS). Recurrence rate was higher in PHS (14.6% vs. 2.6%, p<0.001)

Table 1. Clinical and demographic characteristics of the patientsCharacteristicsPublic (%), n=967Private (%), n=274pDiscovery of BC   By patient530 (54.8)92 (33.5) Routine exam87 (9)109 (39.8) Screening mammography270 (27.9)23 (8.4) Other80 (8.3)50 (18.3)<0.001Initial treatment   Surgery687 (71)241 (88) Neo-adjuvant chemotherapy224 (23.2)27 (9.8) Neo-adjuvant hormone therapy23 (2.3)27 (9.8) Not available33 (3.4)3 (1.1)<0.001Clinical Stage   I293 (30.3)113 (41.2) II342 (35.4)52 (19) III271 (28)15 (5.5) Unknown61 (6.3)94 (34.3)<0.001Subtype   HR+/HER2 -561 (58)192 (70.1) HR-/HER2+108 (11.1)29 (10.6) HR-/HER2+76 (7.9)14 (5.1) Triple negative149 (15.4)28 (10.2) Unknown73 (7.6)11 (4)0.012Symptomatic at Diagnosis   Yes591 (61.1)100 (36.5) No306 (31.6)97 (35.4) Unknown70 (7.2)77 (28.1)<0.001Recurencen=772n=146 No719 (74.4)193 (70.4) Yes142 (14.6)7 (2.6) Unknown106 (11)74 (27)<0.001

. Considering the interval in weeks: symptoms to diagnosis, diagnosis to first treatment (either surgery or neoadjuvant chemotherapy), diagnosis to first systemic treatment, diagnosis to surgical treatment and diagnosis to radiotherapy were longer in public patients (24.1 vs. 8.7; 11.1 vs. 3.5; 18.6 vs. 9.8; 16.9 vs. 5.6; 51.4 vs. 26.1; p<0.001).

Table 2. Delay disparities between public and private health system PublicPrivatepSymptoms to diagnosis   Number of patients575146 Time (weeks)24.1 (0.4-104.9)8.7 (0.0-43.7)<0.001Diagnosis to first treatment   Number of patients663180 Time (weeks)11.1 (2.0-31.5)3.5 (0.0-11.0)<0.001Diagnosis to first systemic treatment   Number of patients526106 Time (weeks)18.6 (2.6-44.7)9.8 (1.9-29.3)<0.001Diagnosis to surgical treatment   Number of patients657178 Time (weeks)16.9 (3.4-45.6)5.6 (0.0-32.9)<0.001Diagnosis to radiotherapy   Number of patients465127 Time (weeks)51.4 (18.7-88.4)26.1 (5.6-66.4)<0.001

In multivariate analysis, PHS (HR 1.72; 95% CI 1.34-1.88; p adj=0.003), presence of symptoms (HR 2.29; 95% CI 1.39-3.78; p adj=0.001), clinical stage III (HR 1.62; 95% CI 1.35-1.93; p adj<0.001), and triple negativity and HER2neu positivity (1.18; 95% CI 1.03-1.35; p adj=0.021) were all associated with a higher recurrence rate.Conclusions: There were significant disparities between PHS and PS. Women in the PHS presented higher rates of recurrence, advanced clinical stages at diagnosis, symptoms and more aggressive subtypes by IHC. additionally, the interval between symptoms to diagnosis and diagnosis to treatments was longer in PHS.

Citation Format: NematiShafaee M, Natal RA, Ramalho S, Dória MT, Conz L, Cabello V, Pavanello M, Mano MS, Linck RDM, Batista LS, Pedro EP, Bines J, de Paula BH, Zucca-Matthes G, Bondy ML, Ellis MJ, Podany E, Debord L, Makawita S, Stewart K, Cabello C. Impact of delay in breast cancer diagnosis and treatment according to health insurance status in southwest Brazil and Houston, Texas [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-15.

[LIMITATIONS OF THE BIOMEDICAL PARADIGM IN GERIATRICS INSTITUTIONS]

The social perception of ageing related to the loss of both physical and psychological functions that determine in many cases the institutionalization of the elderly in nursing homes, leads to a medical care focused on a biomedical model, centered on organic factors as determinants of the illness. Illness is not an isolated condition in an individual, but has a subjective and social dimension. For this reason the biographic history becomes the main reference point in the care of the elderly. People experiment their disease within a narrative that gives a meaning to their experience; but this is not considered by the biomedical model, where the psychosocial factors that influence the onset or progression of the pathology are disregarded. This article attempts to explore the problem that arises when the care of the elderly that reside in geriatric institutions is centered on the biomedical model.

IL7Rα contributes to experimental autoimmune encephalomyelitis through altered T cell responses and nonhematopoietic cell lineages

A mutation in the IL7Rα locus has been identified as a risk factor for multiple sclerosis (MS), a neurodegenerative autoimmune disease characterized by inflammation, demyelination, and axonal damage. IL7Rα has well documented roles in lymphocyte development and homeostasis, but its involvement in disease is largely understudied. In this study, we use the experimental autoimmune encephalomyelitis (EAE) model of MS to show that a less severe form of the disease results when IL7Rα expression is largely restricted to thymic tissue in IL7RTg(IL7R-/-) mice. Compared with wild-type (WT) mice, IL7RTg(IL7R-/-) mice exhibited reduced paralysis and myelin damage that correlated with dampened effector responses, namely decreased TNF production. Furthermore, treatment of diseased WT mice with neutralizing anti-IL7Rα Ab also resulted in significant improvement of EAE. In addition, chimeric mice were generated by bone marrow transplant to limit expression of IL7Rα to cells of either hematopoietic or nonhematopoietic origin. Mice lacking IL7Rα only on hematopoietic cells develop severe EAE, suggesting that IL7Rα expression in the nonhematopoietic compartment contributes to disease. Moreover, novel IL7Rα expression was identified on astrocytes and oligodendrocytes endogenous to the CNS. Chimeric mice that lack IL7Rα only on nonhematopoietic cells also develop severe EAE, which further supports the role of IL7Rα in T cell effector function. Conversely, mice that lack IL7Rα throughout both compartments are dramatically protected from disease. Taken together, these data indicate that multiple cell types use IL7Rα signaling in the development of EAE, and inhibition of this pathway should be considered as a new therapeutic avenue for MS.

Interleukin-7 receptor α contributes to experimental autoimmune encephalomyelitis (171.42)

Multiple sclerosis (MS) is a neurodegenerative disease characterized by inflammation, demyelination, and axonal damage. Recently, a mutation in the interleukin-7 receptor alpha (IL7Rα) locus has been identified as a risk factor for MS. IL7Rα has well-documented roles in lymphocyte development, function, and homeostasis, but its involvement in disease settings is largely understudied. Here we show that IL7Rα defective mice (IL7RTgIL7R-/-) display a less severe form of experimental autoimmune encephalomyelitis (EAE), a model for MS. Compared to wild type (WT), IL7RTgIL7R-/- exhibit reduced levels of paralysis, myelin damage, and inflammation. Furthermore, diseased WT treated with neutralizing anti-IL7Rα show significant recovery in EAE clinical scores and reduced lymphocyte infiltration into the CNS. A series of chimeric mice were then generated by bone marrow (BM) transplantation to identify IL7Rα+ cellular compartments contributing to EAE. Rag-/- mice engrafted with IL7RTgIL7R-/- or WT BM display equivalent disease severity, suggesting that IL7Rα on non-hematopoietic cells contributes to EAE. Lymphodeplete IL7R-/- mice reconstituted with WT or IL7RTgIL7R-/- BM showed dramatic reductions in EAE only with IL7RTgIL7R-/- engraftment and not WT, suggesting that IL7Rα signaling on lymphocytes contributes to disease. Taken together, IL7Rα signaling blockade in multiple cell types is necessary for marked reductions in EAE, and should be considered as a new therapeutic target for MS.

Expansion of a restricted residual host T reg-cell repertoire is dependent on IL-2 following experimental autologous hematopoietic stem transplantation

We previously identified a population of residual T(reg) cells following autologous hematopoietic stem transplantation (HSCT), that rapidly undergoes significant expansion in lymphopenic transplant recipients prior to repopulation by donor de novo derived T(reg) cells. These CD4(+) Foxp3(+) T cells provide protection from the development of autoimmune disease. Although ablative conditioning results in excess IL-7 and IL-15, IL-2 is typically not found at high levels following autologous HSCT. We therefore examined the role of these three STAT-5 signaling cytokines in the expansion of residual T(reg) cells after autologous HSCT. The present study found that the residual T(reg) cell population included surviving peripheral host Foxp3(+) CD4(+) T cells whose expansion was critically dependent on IL-2, which could be solely provided by surviving host cells. IL-7 was found to contribute to T(reg) cell homeostasis, however, not as a growth factor but rather for their persistence. In conjunction with this expansion, TCR spectratype analyses revealed that the residual host T(reg) -cell compartment differed from that present in non-conditioned healthy mice since the residual host Treg cells exhibit a limited TCR diversity. Collectively, these data indicate that the proliferation of T(reg) and T effector (T(eff) ) cells post-HSCT utilize separate pools of cytokines which has important implications regarding the development of clinical strategies to elicit the desired immune responses in patients post-transplant.

Radioguided Intraoperative Margins Evaluation (RIME): Preliminary results of a new technique to aid breast cancer resection

AIMS

Women undergoing breast-conserving surgery for cancer can present residual disease. We have developed a technique called Radioguided Intraoperative Margins Evaluation (RIME) that uses a radiopharmaceutical to distinguish normal and cancer tissues. The aim of this study was to assess whether RIME is a feasible technique, and if it could help in breast cancer resection with free margins, minimizing residual disease.

METHODS

Twenty-three breast cancer patients programmed for mastectomy were selected. Before surgery, the patients were submitted to scintimammography with 99mTc-sestamibi to estimate the optimal time to begin radioguided surgery. Twenty patients were submitted to magnetic resonance imaging (MRI), to evaluate skin, deep fascia and to detect other tumor foci. At the beginning of the surgery, the same dose of 99mTc-sestamibi was intravenously injected into patients. Tumor resection was performed under guidance of a gamma-probe, characterizing the RIME technique. Finally, modified radical mastectomy was performed. Tumor and residual breast were histopathologically examined.

RESULTS

The RIME technique was successfully performed in all patients. The principal tumor was removed by this technique and provided 82.6% of histologically free margins (mean margins, 4.8 mm). Additionally, 47.8% of patients were without residual disease. The mean size of residual carcinoma was 3.67 mm and generally located near the tumor bed (<1.5 cm). There was no significant association between presence of residual disease and tumor size or margin status.

CONCLUSION

RIME is a feasible technique that could help tumor resection with free margins; however, it seems to be limited for small carcinoma foci.

Frequency of viruses associated with acute respiratory infections in children younger than five years of age at a locality of Mexico City

A locality in the district of Tlalpan, Mexico City, was selected in order to identify the viral agents in children younger than 5 years of age with acute respiratory infection (ARI). A total of 300 children were randomly selected and were included in this study for a period of 13 months. During this period nasopharyngeal exudates were collected for the isolation of viral agents. Monoclonal fluorescent antibodies were used for viral identification after cell culture. Viral infection was detected in 65% of the specimens. The respiratory syncytial virus (RSV) was the most common virus agent detected. Children required an average of two consultations during the study period. Two high incidence peaks were observed, one during the summer and the other during winter; the most frequent viruses during these seasons were influenza A and RSV, respectively. The largest number of viruses was isolated in the group of children between 1 and 2 years of age and in the group between 4 and 5 years of age. This study demonstrated the presence of ARI and of different viruses in a period of 13 months, as well as the most frequent viruses in children younger than 5 years of age from a community of Mexico City.

Multiple gene copy number enhances insulin precursor secretion in the yeast Pichia pastoris

We have found a direct relationship between protein production in Pichia pastoris and the number of introduced synthetic genes of miniproinsulin (MPI), fused to the Saccharomyces cerevisiae pre-pro alpha factor used as secretion signal, and inserted between the alcohol oxidase 1 (AOX1) promoter and terminator sequences. Two consecutive approaches were followed to increase the number of integrated cassettes: the head-to-tail expression cassette multimerization procedure and re-transformation with a dominant selection marker. This increased expression from 19 to 250 mg l(-1) when about 11 copies have been integrated. Further, the correct position of one of the disulphide bridges of the purified molecule was verified by digestion with Glu-C endoprotease, followed by mass spectrometry of the isolated fragments.

Modeling of mini-proinsulin production in Pichia pastoris using the AOX promoter

An unstructured model based on mass balance equations for a recombinant methylotrophic yeast Pichia pastoris MutS (Methanol Utilization Slow) strain expressing the mini-proinsulin (MPI), was successfully established in quasi-steady state fed-batch fermentations with varying total quantity of biomass in a 7 l fermenter. The model describes the relationships between the total biomass and induction time, both in the batch and fed-batch phases. In addition, good correlations were obtained when the total quantity of MPI was correlated with the total biomass, demonstrating that the product of interest is associated with growth in the methanol phase. The parameters of the fermentation model obtained are similar to those reported by other researchers.