Validation of the RSClin risk calculator in the National Cancer Data Base

BACKGROUND

Guidelines recommend the use of genomic assays such as OncotypeDx to aid in decisions regarding the use of chemotherapy for hormone receptor-positive, HER2-negative (HR+/HER2-) breast cancer. The RSClin prognostic tool integrates OncotypeDx and clinicopathologic features to predict distant recurrence and chemotherapy benefit, but further validation is needed before broad clinical adoption.

METHODS

This study included patients from the National Cancer Data Base (NCDB) who were diagnosed with stage I-III HR+/HER2- breast cancer from 2010 to 2020 and received adjuvant endocrine therapy with or without chemotherapy. RSClin-predicted chemotherapy benefit was stratified into low (<3% reduction in distant recurrence), intermediate (3%-5%), and high (>5%). Cox models were used to model mortality adjusted for age, comorbidity index, insurance, and race/ethnicity.

RESULTS

A total of 285,441 patients were identified for inclusion from the NCDB, with an average age of 60 years and a median follow-up of 58 months. Chemotherapy was associated with improved overall survival only for those predicted to have intermediate (adjusted hazard ratio [aHR], 0.68; 95% confidence interval [CI], 0.60-0.79) and high benefit per RSClin (aHR, 0.66; 95% CI, 0.61-0.72). Consistent benefit was seen in the subset with a low OncotypeDx score (<26) and intermediate (aHR, 0.66; 95% CI, 0.53-0.82) or high (aHR, 0.71; 95% CI, 0.58-0.86) RSClin-predicted benefit. No survival benefit with chemotherapy was seen in patients with a high OncotypeDx score (≥26) and low benefit per RSClin (aHR, 1.70; 95% CI, 0.41-6.99).

CONCLUSIONS

RSClin may identify high-risk patients who benefit from treatment intensification more accurately than OncotypeDx, and further prospective study is needed.

Slideflow: deep learning for digital histopathology with real-time whole-slide visualization

Deep learning methods have emerged as powerful tools for analyzing histopathological images, but current methods are often specialized for specific domains and software environments, and few open-source options exist for deploying models in an interactive interface. Experimenting with different deep learning approaches typically requires switching software libraries and reprocessing data, reducing the feasibility and practicality of experimenting with new architectures. We developed a flexible deep learning library for histopathology called Slideflow, a package which supports a broad array of deep learning methods for digital pathology and includes a fast whole-slide interface for deploying trained models. Slideflow includes unique tools for whole-slide image data processing, efficient stain normalization and augmentation, weakly-supervised whole-slide classification, uncertainty quantification, feature generation, feature space analysis, and explainability. Whole-slide image processing is highly optimized, enabling whole-slide tile extraction at 40x magnification in 2.5 s per slide. The framework-agnostic data processing pipeline enables rapid experimentation with new methods built with either Tensorflow or PyTorch, and the graphical user interface supports real-time visualization of slides, predictions, heatmaps, and feature space characteristics on a variety of hardware devices, including ARM-based devices such as the Raspberry Pi.

Generative Adversarial Networks Accurately Reconstruct Pan-Cancer Histology from Pathologic, Genomic, and Radiographic Latent Features

Artificial intelligence models have been increasingly used in the analysis of tumor histology to perform tasks ranging from routine classification to identification of novel molecular features. These approaches distill cancer histologic images into high-level features which are used in predictions, but understanding the biologic meaning of such features remains challenging. We present and validate a custom generative adversarial network - HistoXGAN - capable of reconstructing representative histology using feature vectors produced by common feature extractors. We evaluate HistoXGAN across 29 cancer subtypes and demonstrate that reconstructed images retain information regarding tumor grade, histologic subtype, and gene expression patterns. We leverage HistoXGAN to illustrate the underlying histologic features for deep learning models for actionable mutations, identify model reliance on histologic batch effect in predictions, and demonstrate accurate reconstruction of tumor histology from radiographic imaging for a 'virtual biopsy'.

Bilateral asymmetry of quantitative parenchymal kinetics at ultrafast DCE-MRI predict response to neoadjuvant chemotherapy in patients with HER2+ breast cancer

PURPOSE

To assess whether measurement of the bilateral asymmetry of semiquantitative and quantitative perfusion parameters from ultrafast dynamic contrast-enhanced MRI (DCE-MRI), allows early prediction of pathologic response after neoadjuvant chemotherapy (NAC) in patients with HER2+ breast cancer.

MATERIALS AND METHODS

Twenty-eight female patients with HER2+ breast cancer treated with NAC who underwent pre-NAC ultrafast DCE-MRI (3-9 s/phase) were enrolled for this study. Four semiquantitative and two quantitative parenchymal parameters were calculated for each patient. Ipsilateral/contralateral (I/C) ratio (for four parameters) and the difference between (for two parameters) ipsi- and contra-lateral parenchymal kinetic parameters (kBPE) were compared for patients with pathologic complete response (pCR) and those having residual disease. Lasso regression with leave-one-out cross validation was used to determine the optimal combination of parameters for a regression model and multivariable logistic regression was used to identify independent predictors for pCR. Chi-squared test, two-sided t-test and Kruskal-Wallis test were used.

RESULTS

The Ktrans I/C ratio cutoff value of 1.11 had a sensitivity of 83.3% and specificity of 75% for pCR. The ve I/C ratio cutoff value of 1.1 had a sensitivity of 75% and specificity of 81.3% for pCR. The area under the receiver operating characteristic curve of the three-kBPE parameter model, including initial area under the enhancement curve (AUC30) I/C ratio, KtransI/C ratio and ve I/C ratio, was 0.89 with sensitivity of 91.7% at specificity of 81.3%.

CONCLUSION

Quantitative assessment of bilateral asymmetry kBPE from pre-NAC ultrafast DCE-MRI can predict pCR in patients with HER2+ breast cancer.

External Evaluation of a Mammography-based Deep Learning Model for Predicting Breast Cancer in an Ethnically Diverse Population

Purpose

To externally evaluate a mammography-based deep learning (DL) model (Mirai) in a high-risk racially diverse population and compare its performance with other mammographic measures.

Materials and Methods

A total of 6435 screening mammograms in 2096 female patients (median age, 56.4 years ± 11.2 [SD]) enrolled in a hospital-based case-control study from 2006 to 2020 were retrospectively evaluated. Pathologically confirmed breast cancer was the primary outcome. Mirai scores were the primary predictors. Breast density and Breast Imaging Reporting and Data System (BI-RADS) assessment categories were comparative predictors. Performance was evaluated using area under the receiver operating characteristic curve (AUC) and concordance index analyses.

Results

Mirai achieved 1- and 5-year AUCs of 0.71 (95% CI: 0.68, 0.74) and 0.65 (95% CI: 0.64, 0.67), respectively. One-year AUCs for nondense versus dense breasts were 0.72 versus 0.58 (P = .10). There was no evidence of a difference in near-term discrimination performance between BI-RADS and Mirai (1-year AUC, 0.73 vs 0.68; P = .34). For longer-term prediction (2-5 years), Mirai outperformed BI-RADS assessment (5-year AUC, 0.63 vs 0.54; P < .001). Using only images of the unaffected breast reduced the discriminatory performance of the DL model (P < .001 at all time points), suggesting that its predictions are likely dependent on the detection of ipsilateral premalignant patterns.

Conclusion

A mammography DL model showed good performance in a high-risk external dataset enriched for African American patients, benign breast disease, and BRCA mutation carriers, and study findings suggest that the model performance is likely driven by the detection of precancerous changes.Keywords: Breast, Cancer, Computer Applications, Convolutional Neural Network, Deep Learning Algorithms, Informatics, Epidemiology, Machine Learning, Mammography, Oncology, Radiomics Supplemental material is available for this article. © RSNA, 2023See also commentary by Kontos and Kalpathy-Cramer in this issue.

Deep learning generates synthetic cancer histology for explainability and education

Artificial intelligence methods including deep neural networks (DNN) can provide rapid molecular classification of tumors from routine histology with accuracy that matches or exceeds human pathologists. Discerning how neural networks make their predictions remains a significant challenge, but explainability tools help provide insights into what models have learned when corresponding histologic features are poorly defined. Here, we present a method for improving explainability of DNN models using synthetic histology generated by a conditional generative adversarial network (cGAN). We show that cGANs generate high-quality synthetic histology images that can be leveraged for explaining DNN models trained to classify molecularly-subtyped tumors, exposing histologic features associated with molecular state. Fine-tuning synthetic histology through class and layer blending illustrates nuanced morphologic differences between tumor subtypes. Finally, we demonstrate the use of synthetic histology for augmenting pathologist-in-training education, showing that these intuitive visualizations can reinforce and improve understanding of histologic manifestations of tumor biology.

Molecular profiling of a real-world breast cancer cohort with genetically inferred ancestries reveals actionable tumor biology differences between European ancestry and African ancestry patient populations

BACKGROUND

Endocrine-resistant HR+/HER2- breast cancer (BC) and triple-negative BC (TNBC) are of interest for molecularly informed treatment due to their aggressive natures and limited treatment profiles. Patients of African Ancestry (AA) experience higher rates of TNBC and mortality than European Ancestry (EA) patients, despite lower overall BC incidence. Here, we compare the molecular landscapes of AA and EA patients with HR+/HER2- BC and TNBC in a real-world cohort to promote equity in precision oncology by illuminating the heterogeneity of potentially druggable genomic and transcriptomic pathways.

METHODS

De-identified records from patients with TNBC or HR+/HER2- BC in the Tempus Database were randomly selected (N = 5000), with most having stage IV disease. Mutations, gene expression, and transcriptional signatures were evaluated from next-generation sequencing data. Genetic ancestry was estimated from DNA-seq. Differences in mutational prevalence, gene expression, and transcriptional signatures between AA and EA were compared. EA patients were used as the reference population for log fold-changes (logFC) in expression.

RESULTS

After applying inclusion criteria, 3433 samples were evaluated (n = 623 AA and n = 2810 EA). Observed patterns of dysregulated pathways demonstrated significant heterogeneity among the two groups. Notably, PIK3CA mutations were significantly lower in AA HR+/HER2- tumors (AA = 34% vs. EA = 42%, P < 0.05) and the overall cohort (AA = 28% vs. EA = 37%, P = 2.08e-05). Conversely, KMT2C mutation was significantly more frequent in AA than EA TNBC (23% vs. 12%, P < 0.05) and HR+/HER2- (24% vs. 15%, P = 3e-03) tumors. Across all subtypes and stages, over 8000 genes were differentially expressed between the two ancestral groups including RPL10 (logFC = 2.26, P = 1.70e-162), HSPA1A (logFC = - 2.73, P = 2.43e-49), ATRX (logFC = - 1.93, P = 5.89e-83), and NUTM2F (logFC = 2.28, P = 3.22e-196). Ten differentially expressed gene sets were identified among stage IV HR+/HER2- tumors, of which four were considered relevant to BC treatment and were significantly enriched in EA: ERBB2_UP.V1_UP (P = 3.95e-06), LTE2_UP.V1_UP (P = 2.90e-05), HALLMARK_FATTY_ACID_METABOLISM (P = 0.0073), and HALLMARK_ANDROGEN_RESPONSE (P = 0.0074).

CONCLUSIONS

We observed significant differences in mutational spectra, gene expression, and relevant transcriptional signatures between patients with genetically determined African and European ancestries, particularly within the HR+/HER2- BC and TNBC subtypes. These findings could guide future development of treatment strategies by providing opportunities for biomarker-informed research and, ultimately, clinical decisions for precision oncology care in diverse populations.

Evaluation of multigene assays as predictors for response to neoadjuvant chemotherapy in early-stage breast cancer patients

OncotypeDX and MammaPrint assays have not been validated to predict pathologic complete response (pCR) to neoadjuvant chemotherapy (NACT) in early-stage breast cancer patients. We analyzed the 2010-2019 National Cancer Database and found that high OncotypeDX recurrence scores or high MammaPrint scores were associated with greater odds of pCR. Our findings suggest that OncotypeDX and MammaPrint testing predict pCR after NACT and could facilitate clinical decision-making between clinicians and patients.

The impact of race and age on response to neoadjuvant therapy and long-term outcomes in Black and White women with early-stage breast cancer

PURPOSE

There are a paucity of data and a pressing need to evaluate response to neoadjuvant chemotherapy (NACT) and determine long-term outcomes in young Black women with early-stage breast cancer (EBC).

METHODS

We analyzed data from 2196 Black and White women with EBC treated at the University of Chicago over the last 2 decades. Patients were divided into groups based on race and age at diagnosis: Black women [Formula: see text] 40 years, White women [Formula: see text] 40 years, Black women [Formula: see text] 55 years, and White women [Formula: see text] 55 years. Pathological complete response rate (pCR) was analyzed using logistic regression. Overall survival (OS) and disease-free survival (DFS) were analyzed using Cox proportional hazard and piecewise Cox models.

RESULTS

Young Black women had the highest risk of recurrence, which was 22% higher than young White women (p = 0.434) and 76% higher than older Black women (p = 0.008). These age/racial differences in recurrence rates were not statistically significant after adjusting for subtype, stage, and grade. In terms of OS, older Black women had the worst outcome. In the 397 women receiving NACT, 47.5% of young White women achieved pCR, compared to 26.8% of young Black women (p = 0.012).

CONCLUSIONS

Black women with EBC had significantly worse outcomes compared to White women in our cohort study. There is an urgent need to understand the disparities in outcomes between Black and White breast cancer patients, particularly in young women where the disparity in outcome is the greatest.

Comparing scientific abstracts generated by ChatGPT to real abstracts with detectors and blinded human reviewers

Large language models such as ChatGPT can produce increasingly realistic text, with unknown information on the accuracy and integrity of using these models in scientific writing. We gathered fifth research abstracts from five high-impact factor medical journals and asked ChatGPT to generate research abstracts based on their titles and journals. Most generated abstracts were detected using an AI output detector, 'GPT-2 Output Detector', with % 'fake' scores (higher meaning more likely to be generated) of median [interquartile range] of 99.98% 'fake' [12.73%, 99.98%] compared with median 0.02% [IQR 0.02%, 0.09%] for the original abstracts. The AUROC of the AI output detector was 0.94. Generated abstracts scored lower than original abstracts when run through a plagiarism detector website and iThenticate (higher scores meaning more matching text found). When given a mixture of original and general abstracts, blinded human reviewers correctly identified 68% of generated abstracts as being generated by ChatGPT, but incorrectly identified 14% of original abstracts as being generated. Reviewers indicated that it was surprisingly difficult to differentiate between the two, though abstracts they suspected were generated were vaguer and more formulaic. ChatGPT writes believable scientific abstracts, though with completely generated data. Depending on publisher-specific guidelines, AI output detectors may serve as an editorial tool to help maintain scientific standards. The boundaries of ethical and acceptable use of large language models to help scientific writing are still being discussed, and different journals and conferences are adopting varying policies.

Integration of clinical features and deep learning on pathology for the prediction of breast cancer recurrence assays and risk of recurrence

Gene expression-based recurrence assays are strongly recommended to guide the use of chemotherapy in hormone receptor-positive, HER2-negative breast cancer, but such testing is expensive, can contribute to delays in care, and may not be available in low-resource settings. Here, we describe the training and independent validation of a deep learning model that predicts recurrence assay result and risk of recurrence using both digital histology and clinical risk factors. We demonstrate that this approach outperforms an established clinical nomogram (area under the receiver operating characteristic curve of 0.83 versus 0.76 in an external validation cohort, p = 0.0005) and can identify a subset of patients with excellent prognoses who may not need further genomic testing.

Clinicopathologic Characteristics and Prognosis of ERBB2-Low Breast Cancer Among Patients in the National Cancer Database

Importance

Given conflicting results regarding the prognosis of erb-b2 receptor tyrosine kinase 2 (ERBB2; formerly HER2 or HER2/neu)-low breast cancer, a large-scale, nationally applicable comparison of ERBB2-low vs ERBB2-negative breast cancer is needed.

Objective

To investigate whether ERBB2-low breast cancer is a clinically distinct subtype in terms of epidemiological characteristics, prognosis, and response to neoadjuvant chemotherapy.

Design/Participants/Setting

This retrospective cohort study was conducted using the National Cancer Database, including 1 136 016 patients in the US diagnosed with invasive breast cancer from January 1, 2010, to December 31, 2019, who had ERBB2-negative disease and had immunohistochemistry results available. ERBB2-low tumors were classified as having an immunohistochemistry score of 1+, or 2+ with a negative in situ hybridization test. Data were analyzed from November 1, 2021, through November 30, 2022.

Exposures

Standard therapy according to routine clinical practice.

Main Outcomes and Measures

The primary outcomes were overall survival (OS), reported as adjusted hazard ratios (aHRs), and pathologic complete response, reported as adjusted odds ratios (aORs), for ERBB2-negative vs ERBB2-low breast cancer, controlling for age, sex, race and ethnicity, Charlson-Deyo Comorbidity Index score, treatment facility type, tumor grade, tumor histology, hormone receptor status, and cancer stage.

Results

The study identified 1 136 016 patients (mean [SD] age, 62.4 [13.1] years; 99.1% female; 78.6% non-Hispanic White), of whom 392 246 (34.5%) were diagnosed with ERBB2-negative and 743 770 (65.5%) with ERBB2-low breast cancer. The mean (SD) age of the ERBB2-negative group was 62.1 (13.2) years and 62.5 (13.0) years for the ERBB2-low group. Higher estrogen receptor expression was associated with increased rates of ERBB2-low disease (aOR, 1.15 per 10% increase). Compared with non-Hispanic White patients, of whom 66.1% were diagnosed with ERBB2-low breast cancer, fewer non-Hispanic Black (62.8%) and Hispanic (61.0%) patients had ERBB2-low disease, although in non-Hispanic Black patients this was mediated by differences in rates of triple-negative disease and other confounders. A slightly lower rate of pathologic complete response was seen in patients with ERBB2-low disease vs patients with ERBB2-negative disease on multivariable analysis (aOR, 0.89; 95% CI, 0.86-0.92; P < .001). ERBB2-low status was also associated with small improvements in OS for stage III (aHR, 0.92; 95% CI, 0.89-0.96; P < .001) and stage IV (aHR, 0.91; 95% CI, 0.87-0.96; P < .001) triple-negative breast cancer, although this amounted to only a 2.0% (stage III) and 0.4% (stage IV) increase in 5-year OS.

Conclusions and Relevance

This large-scale retrospective cohort analysis found minimal prognostic differences between ERBB2-low and ERBB2-negative breast cancer. These findings suggest that, moving forward, outcomes in ERBB2-low breast cancer will be driven by ERBB2-directed antibody-drug conjugates, rather than intrinsic differences in biological characteristics associated with low-level ERBB2 expression. These findings do not support the classification of ERBB2-low breast cancer as a unique disease entity.

The Impact of Race and Age on Response to Neoadjuvant Therapy and Long-Term Outcomes in Black and White Women with Early-Stage Breast Cancer

PURPOSE

There are a paucity of data and a pressing need to evaluate response to neoadjuvant chemotherapy (NACT) and determine long-term outcomes in young Black women with early-stage breast cancer (EBC).

METHODS

We analyzed data from 2,196 Black and White women with EBC treated at the University of Chicago over the last 2 decades. Patients were divided into groups based on race and age at diagnosis: Black women 40 years, White women 40 years, Black women 55 years, and White women 55 years. Pathological complete response rate (pCR) was analyzed using logistic regression. Overall survival (OS) and disease-free survival (DFS) were analyzed using Cox proportional hazard and piecewise Cox models.

RESULTS

Young Black women had the highest risk of recurrence, which was 22% higher than young White women (p=0.434) and 76% higher than older Black women (p=0.008). These age/racial differences in recurrence rates were not statistically significant after adjusting for subtype, stage, and grade. In terms of OS, older Black women had the worst outcome. In the 397 women receiving NACT, 47.5% of young White women achieved pCR, compared to 26.8% of young Black women (p=0.012).

CONCLUSIONS

Black women with EBC had significantly worse outcomes compared to White women in our cohort study. There is an urgent need to understand the disparities in outcomes between Black and White breast cancer patients, particularly in young women where the disparity in outcome is the greatest.

Abstract HER2-11: HER2-11 Epidemiology and Prognosis of HER2-Low Breast Cancer (BC) in the National Cancer Data Base (NCDB)

Title: Epidemiology and Prognosis of HER2-Low Breast Cancer (BC) in the National Cancer Data Base (NCDB) Background: Characterization of HER2 status has focused on HER2 overexpressing BC, which are uniquely sensitive to HER2-directed therapy. However, approximately 60% of BC traditionally characterized as HER2-negative express low levels of HER2 on immunohistochemistry (IHC). Although these ‘HER2-low’ cancers are insensitive to traditional HER2 blockade, a recent randomized clinical trial showed that antibody drug conjugates such as trastuzumab deruxtecan (T-DXd) are effective in this population. Given the heterogenity of low level HER2 expression and the impact of T-DXd on outcomes in this population, further data on the epidemiology and prognosis of HER2-low BC is needed. Methods: We conducted a retrospective cohort study of patients (pts) in the NCDB diagnosed from 2010 to 2019 with invasive BC classified as HER2-negative, and with HER2 IHC results available. We compared demographics and other clinical characteristics of HER2 0 vs HER2-low (defined as IHC score of 1+ or 2+) cases in this cohort. A logistic regression was used to quantify the independent association of demographic and clinical factors with HER2-low status, and odds ratios (OR) and 95% confidence intervals (CI) were reported. Overall survival (OS) was compared for HER2 0 vs HER2-low by receptor subtype and stage, and a multivariable Cox model was fit to also control for age, race/ethnicity, comorbidity score, treatment facility type, grade, and histologic type. In pts who received neoadjuvant chemotherapy (NAC), a logistic regression was used to determine if pathological complete response (pCR) rate was different between HER2-low and HER2 0 pts. Results: We identified 1,191,389 pts, including 394,937 HER2 0 and 796,452 HER2-low; median follow-up was 54 months with 84.1% of pts surviving. Hispanic and Black pts and pts with higher grade, non-ductal, triple-negative breast cancer (TNBC) and affect minority Hispanic and Black women (table 1). On multivariable analysis, TNBC (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.47 – 0.49), lobular (OR 0.74, 95% CI 0.73 – 0.75) and other non-ductal histology (OR 0.66, 95% CI 0.64 – 0.67) had lower likelihood of HER2-low status. Hispanic ethnicity remained associated with lower likelihood of HER2-low (OR 0.89, 95% CI 0.87 – 0.91), whereas Black race was associated with a slight increased likelihood of HER2-low status (OR 1.06, 95% CI 1.04 – 1.08). In multivariable survival analysis of TNBC patients, HER2-low BC was associated with improved OS for stage 2 (hazard ratio [HR] 0.93, 95% CI 0.90 – 0.96), stage 3 (HR 0.92, 95% CI 0.88 – 0.96) and stage 4 (HR 0.92, 95% CI 0.87 – 0.97) cancer. By contrast, survival analysis of hormone receptor positive cancer showed that HER2-low BC was associated with improved OS only for stage 4 disease (HR 0.96, 95% CI 0.92 – 0.99). In 62,667 pts receiving NAC, HER2-low status was associated with a lower likelihood of pCR (OR 0.88, 95% CI 0.84 – 0.92). Conclusions: HER2-low BC is most frequently HR+ with a ductal histology, and is associated with a lower likelihood of response to chemotherapy but an improved OS, especially for metastatic cases. This lower pCR in the HER2-low population could be explained by a higher proportion of these tumors being HR+. There are racial/ethnic differences in the incidence of HER2-low BC, largely mediated by differences in rates of TNBC, and fewer Black and Hispanic pts will be candidates for therapies targeting low level HER2 expression.

Citation Format: Daniel Peiffer, Frederick M. Howard, Nan Chen, Olwen M. Hahn, Rita Nanda, Olufunmilayo I. Olopade, Dezheng Huo. HER2-11 Epidemiology and Prognosis of HER2-Low Breast Cancer (BC) in the National Cancer Data Base (NCDB) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr HER2-11.

Response to Treatment, Racial and Ethnic Disparity, and Survival in Patients With Breast Cancer Undergoing Neoadjuvant Chemotherapy in the US

Importance

With the increasing delivery of neoadjuvant chemotherapy (NACT) for patients with breast cancer in the US, it is important to know whether there is differential response to NACT by race and ethnicity and the potential long-term outcomes.

Objective

To examine whether there were any racial and ethnic differences in pathologic complete response (pCR) rate following NACT and, if so, whether they varied by molecular subtype and were associated with survival.

Design, Setting, and Participants

A retrospective cohort study was conducted including patients with stage I to III breast cancer diagnosed between January 2010 and December 2017 who underwent surgery and received NACT; median follow-up was 5.8 years, and data analysis was conducted from August 2021 to January 2023. Data were obtained from the National Cancer Data Base, a nationwide, facility-based, oncology data set that captures approximately 70% of all newly diagnosed cases of breast cancer in the US.

Main Outcomes and Measures

Pathologic complete response, defined as ypT0/Tis ypN0, was modeled using logistic regression. Racial and ethnic differences in survival were analyzed using a Weibull accelerated failure time model. Mediation analysis was conducted to measure whether racial and ethnic differences in the pCR rate affect survival.

Results

The study included 107 207 patients (106 587 [99.4%] women), with a mean (SD) age of 53.4 (12.1) years. A total of 5009 patients were Asian or Pacific Islander, 18 417 were non-Hispanic Black, 9724 were Hispanic, and 74 057 were non-Hispanic White. There were significant racial and ethnic differences in pCR rates, but the differences were subtype-specific. In hormone receptor-negative (HR-)/erb-b2 receptor tyrosine kinase 2 (ERBB2; formerly HER2 or HER2/neu)-positive (ERBB2+) subtype, Asian and Pacific Islander patients achieved the highest pCR rate (56.8%), followed by Hispanic (55.2%) and non-Hispanic White (52.3%) patients with the lowest pCR rate seen in Black patients (44.8%). In triple-negative breast cancer, Black patients had a lower pCR rate (27.3%) than other racial and ethnic groups (all >30%). In HR+/ERBB2- subtype, Black patients had a higher pCR rate (11.3%) than other racial/ethnic groups (all ≤10%). In mediation analysis, racial and ethnic differences in achieving pCR after NACT could explain approximately 20% to 53% of the subtype-specific survival differences across racial and ethnic groups.

Conclusions and Relevance

In this cohort study of patients with breast cancer receiving NACT, Black patients had a lower pCR rate for triple-negative and HR-/ERBB2+ breast cancer but a higher pCR rate for HR+/ERBB2- diseases, whereas Asian and Pacific Islander patients had a higher pCR rate for HR-/ERBB2+ diseases. Tumor grade and ERBB2 copy number could account for some of these within-subtype disparities, but further studies are warranted. Inability to achieve a pCR can mediate in part, but not entirely, the worse survival outcomes experienced by Black patients.

Abstract P2-11-08: Multimodal Prediction of Breast Cancer Recurrence Assays and Risk of Recurrence

Background: Hormone receptor positive breast cancer constitutes about 70% of newly diagnosed early-stage disease in the United States, and gene-expression based recurrence assays such as Oncotype DX (ODX) are strongly recommended by guidelines to aid in treatment decisions. However, recurrence assays are costly, time-consuming, underutilized in low resource settings, and unavailable in developing countries. Deep Learning (DL) using hematoxylin and eosin (H&E) stained digital pathology has been shown to approximate gene expression patterns for multiple cancer types, and may provide a cost-effective, fast, and scalable method to predict risk of recurrence in community settings. Methods: We first developed a model for ODX using only DL on pathology, comprised of two Xception-based modules, trained on 1,039 slides from The Cancer Genome Atlas (TCGA) tessellated into 10x magnification image tiles. The first module predicts tumor likelihood, and was trained using pathologist annotations for tumor regions versus normal stroma. The second module was trained to predict ODX score, estimated from gene expression data within TCGA. Patient-level predictions were calculated by weighting the predicted recurrence score by tumor likelihood for all tiles within a slide. Separately, ODX score was predicted from clinical variables using the University of Tennessee Nomogram, which incorporates grade, progesterone receptor, size, age, and histologic subtype. Finally, we developed a combined model by fitting a logistic regression to the DL pathologic model and the clinical nomogram predictions. Performance of the clinical nomogram, pathologic, and combined models were then compared in a single-institution external validation cohort of patients diagnosed with breast cancer between 2006 and 2020, all of whom had the commercial ODX assay run. Results: We identified 428 cases for our diverse validation cohort (69% White, 24% Black, 6% Asian, and 3% Hispanic) with mean ODX score of 18. Chemotherapy was administered for 104 (24.3%) of patients, the remaining 323 (75.4%) received endocrine therapy alone. Area under the receiver operating characteristic curve (AUROC) for prediction of high ODX score (≥ 26) of the combined model was 0.83 (95% confidence interval [CI] 0.78 – 0.89) in the validation cohort, which was higher than either the DL pathology model (AUROC 0.80, 95% CI 0.75 – 0.85, p = 0.026) or the Tennessee nomogram (AUROC 0.77, 85% CI 0.70 – 0.83, p = 0.003). Performance was similar in Black (AUROC 0.86, 95% CI 0.78 – 0.94) and White (AUROC of 0.81, 95% CI 0.74 – 0.88) subgroups. The combined model was more accurate in prediction of recurrence-free interval in patients receiving endocrine therapy (hazard ratio [HR] 2.02 per standard deviation [SD], 95% CI 1.16 – 3.52, p = 0.013, Concordance [C]-index 0.75) than the clinical nomogram (HR 1.75 per SD, 95% CI 1.09 – 2.81, p = 0.021, C-index 0.68). No model was prognostic in patients receiving chemotherapy. Pathologist review of heatmaps of DL model predictions identified lymphovascular invasion, necrosis, high grade, and infiltrative borders as features contributing to model prediction of high risk. Conclusions: DL can improve on existing clinical prediction of breast cancer with low recurrence risk. This approach could improve the speed at which treatment decisions are made due to the time-consuming nature of genomic testing and simultaneously reduce the cost of care. Given the equal performance in racial subgroups, this approach has promise for application in global health settings where genomic assays are not widely available or are prohibitively expensive.

Citation Format: Frederick M. Howard, James M. Dolezal, Sara Kochanny, Galina Khramtsova, Jasmine Vickery, Andrew Srisuwananukorn, Anna Woodard, Nan Chen, Rita Nanda, Charles Perou, Olufunmilayo I. Olopade, Dezheng Huo, Alexander Pearson. Multimodal Prediction of Breast Cancer Recurrence Assays and Risk of Recurrence [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-11-08.

Abstract P5-03-18: Co-occurring alterations in PALB2 germline carriers identified by liquid biopsy in patients with advanced breast cancer

Introduction: PALB2 is a BRCA complex-interacting protein and has an essential role in homologous recombination and repair (HRR). PALB2 germline (gPALB2) mutations are found in 1 – 4% of breast cancer patients and can be incidentally identified by liquid biopsy testing. Recent data has shown the efficacy for PARP inhibitors (PARPi) in breast cancer gPALB2 carriers, highlighting the importance of understanding genomic drivers in this group of patients. Here we present the genomic landscape of patients with advanced breast cancer (aBC) with incidental gPALB2 mutations identified by liquid biopsy testing. Methods: Genomic results were queried for aBC patients who had Guardant360 (G360) testing as part of routine clinical care from October 2020 – March 2022. Eligible patients had must have a diagnosis of breast cancer and an incidental gPALB2 alteration identified on G360, defined by presence of ClinVar loss-of-function single nucleotide variant (SNV)/indel mutation. Co-occurring somatic alterations in these patients were then analyzed after removing synonymous and variants of uncertain significance. Analysis of HRR-related alterations, such as loss of heterozygosity and/or copy number loss, was performed in a subset of patients. Clinical demographics and clinical status (newly diagnosed or progressing at the time of G360 testing), were extracted from test requisition forms. Results: A total of 48 patients had gPALB2 alterations: 60% had indels and 40% SNVs. gPALB2 variant allele frequencies (VAF) were &gt;30% for all patients (median VAF: 49.7, range: 34.1-66.6). All patients were female with a median age of 59 years (range: 31-84); 29 (60%) were tested at progression whereas the rest were tested at diagnosis. 36 (75%) patients with gPALB2 had co-occurring somatic alterations across 23 genes. The most commonly mutated genes were TP53 (47%), ESR1 (23%), and PIK3CA (19%); other mutated genes had less than 7% frequency. Notably, 95% of patients with co-occurring ESR1 alterations and 70% found to harbor PIK3CA co-occurring alterations were tested at progression. Other clinically relevant findings include co-occurring somatic alterations in MTOR (4%) and HRR-related genes ATM, ARID1A, CHEK2, FANCA (4% each; one patient had both ATM and CHEK2 somatic alterations). No somatic BRCA1/BRCA2 alterations were identified in gPALB2 patients. For 33 (69%) patients with gPALB2, additional HRR-related biomarker analysis was performed resulting in identification of 3 (9%) patients with copy number loss, one who had CHEK2 and PALB2 single copy number loss, resulting in PALB2 biallelic loss. In the overall cohort, an additional 33 patients were identified with uniquely somatic PALB2 alterations. Conclusions: Carriers of gPALB2 alterations comprise a rare subset of aBC patients analyzed by liquid biopsy. These patients have co-occurring somatic alterations identified in genes that have been reported in published cohorts of aBC patients without gPALB2 alterations. Assessment of additional somatic HRR-related alterations may identify other patients with PALB2 findings who could benefit from PARPi. Clinical studies are needed to assess how patients with gPALB2 and co-occurring mutations may have altered response and/or resistance to therapies, including standard-of-care regimens and PARPi.

Citation Format: Nan Chen, Rita Nanda, Frederick M. Howard, Neelima Vidula, Jennifer Yen, Leylah M. Drusbosky, Leslie Bucheit. Co-occurring alterations in PALB2 germline carriers identified by liquid biopsy in patients with advanced breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-03-18.

Abstract P6-01-25: Evaluation of Multigene Assays as Predictors for Response to Neoadjuvant Chemotherapy in Early-Stage Breast Cancer Patients

Background: Oncotype DX (ODX) and MammaPrint (MP) are gene-expression assays that have been established to predict distant cancer recurrence in the adjuvant chemotherapy setting. However, they have not been validated to predict pathologic complete response (pCR) to neoadjuvant chemotherapy (NACT). We sought to examine the ability of the ODX and MP assays to predict the likelihood of pCR to NACT in early-stage breast cancer patients. Methods: Data from breast cancer patients diagnosed between 2010 and 2019 were obtained from the National Cancer Database. All patients who received NACT (at least 30 days of treatment) and had pathologic response data and ODX or MP results were included. Analysis of ODX was limited to patients with hormone receptor (HR)+/HER2- stage I-III disease, while analysis of MP included both HR+/HER2- and HR-/HER2- stage I-III patients. ODX scores were modeled both as a continuous variable and a categorical variable classified as low (0-25) and high (≥26) per the TAILORx trial cutoff, whereas MP results were modeled as a dichotomous variable (i.e., low risk and high risk) because numeric values were unavailable. Multivariable logistic regression models were used to assess the relationship between pCR (defined as ypT0/Tis ypN0) and ODX or MP results, adjusting for age, race/ethnicity, clinical T and N stages, tumor grade, and progesterone receptor status. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated. Results: A total of 2,219 patients, treated at 630 institutions, who received NACT with an ODX recurrence score were included in the ODX cohort. Of 1,181 patients with a high ODX score, 11.2% achieved pCR, while only 1.6% of 867 patients with a low ODX score did. In the adjusted model, having a high ODX score was associated with greater odds of pCR (AOR = 4.48, 95% CI: 2.44-8.22). There was a significant monotonic increasing trend of pCR by continuous ODX score. The mean ODX score was 42.5 (SD = 15.5) in patients who achieved pCR, compared to 27.9 (SD = 13.7) in patients who did not; the discriminating capacity of ODX was moderate to strong (area under the ROC curve = 0.767). A total of 1,349 patients, treated at 337 institutions, who received NACT and had MP test results were included in the MP cohort. Of 1,141 patients with MP high risk disease, 11.8% achieved pCR, compared to &lt; 4.8% of 208 patients with MP low risk disease. In the adjusted model, having MP high risk disease was associated with greater odds of pCR (AOR = 2.21, 95% CI: 1.02-4.77). A similar association between MP results and pCR was also found in the subset of patients who were HR+/HER2- (AOR = 2.25, 95% CI: 0.99-5.15). Conclusions: Both ODX and MP were independently associated with likelihood of pCR after NACT for early-stage, high-risk breast cancer. These findings suggest a potential role for ODX or MP testing as a predictive biomarker in the NACT setting, and can facilitate clinical decision making between physicians and patients.

Citation Format: Jincong Q. Freeman, Sarah Shubeck, Frederick M. Howard, Nan Chen, Rita Nanda, Dezheng Huo. Evaluation of Multigene Assays as Predictors for Response to Neoadjuvant Chemotherapy in Early-Stage Breast Cancer Patients [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-25.

Towards Patient-Specific Optimization of Neoadjuvant Treatment Protocols for Breast Cancer Based on Image-Guided Fluid Dynamics

OBJECTIVE

This study establishes a fluid dynamics model personalized with patient-specific imaging data to optimize neoadjuvant therapy (i.e., doxorubicin) protocols for breast cancers.

METHODS

Ten patients recruited at the University of Chicago were included in this study. Quantitative dynamic contrast-enhanced and diffusion weighted magnetic resonance imaging data are leveraged to estimate patient-specific hemodynamic properties, which are then used to constrain the mechanism-based drug delivery model. Then, computer simulations of this model yield the subsequent drug distribution throughout the breast. By systematically varying the dosing schedule, we identify an optimized regimen for each patient using the maximum safe therapeutic duration (MSTD), which is a metric balancing treatment efficacy and toxicity.

RESULTS

With an individually optimized dose (range = 12.11-15.11 mg/m2 per injection), a 3-week regimen consisting of a uniform daily injection significantly outperforms all other scheduling strategies (P < 0.001). In particular, the optimal protocol is predicted to significantly outperform the standard protocol (P < 0.001), improving the MSTD by an average factor of 9.93 (range = 6.63 to 14.17).

CONCLUSION

A clinical-mathematical framework was developed by integrating quantitative MRI data, advanced image processing, and computational fluid dynamics to predict the efficacy and toxicity of neoadjuvant therapy protocols, thus enabling the rational identification of an optimal therapeutic regimen on a patient-specific basis.

SIGNIFICANCE

Our clinical-computational approach has the potential to enable optimization of therapeutic regimens on a patient-specific basis and provide guidance for prospective clinical trials aimed at refining neoadjuvant therapy protocols for breast cancers.

Differences Between Ipsilateral and Contralateral Early Parenchymal Enhancement Kinetics Predict Response of Breast Cancer to Neoadjuvant Therapy

RATIONALE AND OBJECTIVES

To determine whether kinetics measured with ultrafast dynamic contrast-enhanced magnetic resonance imaging in tumor and normal parenchyma pre- and post-neoadjuvant therapy (NAT) can predict the response of breast cancer to NAT.

MATERIALS AND METHODS

Twenty-four patients with histologically confirmed invasive breast cancer were enrolled. They were scanned with ultrafast dynamic contrast-enhanced magnetic resonance imaging (3-7 seconds/frame) pre- and post-NAT. Four kinetic parameters were calculated in the segmented tumors, and ipsi- and contra-lateral normal parenchyma: (1) tumor (tSE30) or background parenchymal relative enhancement at 30 seconds (BPE30), (2) maximum relative enhancement slope (MaxSlope), (3) bolus arrival time (BAT), and (4) area under relative signal enhancement curve for the initial 30 seconds (AUC30). The tumor kinetics and the differences between ipsi- and contra-lateral parenchymal kinetics were compared for patients achieving pathologic complete response (pCR) vs those who had residual disease after NAT. The chi-squared test and two-sided t-test were used for baseline demographics. The Wilcoxon rank sum test and one-way analysis of variance were used for differential responses to therapy.

RESULTS

Patients with similar pre-NAT mean BPE30, median BAT and mean AUC30 in the ipsi- and contralateral normal parenchyma were more likely to achieve pCR following NAT (p < 0.02). Patients classified as having residual cancer burden (RCB) II after NAT showed higher post-NAT tSE30 and tumor AUC30 and higher post-NAT MaxSlope in ipsilateral normal parenchyma compared to those classified as RCB I or pCR (p < 0.05).

CONCLUSION

Bilateral asymmetry in normal parenchyma could predict treatment outcome prior to NAT. Post-NAT tumor kinetics could evaluate the aggressiveness of residual tumor.

Highly accurate response prediction in high-risk early breast cancer patients using a biophysical simulation platform

PURPOSE

Pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) in early breast cancer (EBC) is largely dependent on breast cancer subtype, but no clinical-grade model exists to predict response and guide selection of treatment. A biophysical simulation of response to NAC has the potential to address this unmet need.

METHODS

We conducted a retrospective evaluation of a biophysical simulation model as a predictor of pCR. Patients who received standard NAC at the University of Chicago for EBC between January 1st, 2010 and March 31st, 2020 were included. Response was predicted using baseline breast MRI, clinicopathologic features, and treatment regimen by investigators who were blinded to patient outcomes.

RESULTS

A total of 144 tumors from 141 patients were included; 59 were triple-negative, 49 HER2-positive, and 36 hormone-receptor positive/HER2 negative. Lymph node disease was present in half of patients, and most were treated with an anthracycline-based regimen (58.3%). Sensitivity and specificity of the biophysical simulation for pCR were 88.0% (95% confidence interval [CI] 75.7 - 95.5) and 89.4% (95% CI 81.3 - 94.8), respectively, with robust results regardless of subtype. In patients with predicted pCR, 5-year event-free survival was 98%, versus 79% with predicted residual disease (log-rank p = 0.01, HR 4.57, 95% CI 1.36 - 15.34). At a median follow-up of 5.4 years, no patients with predicted pCR experienced disease recurrence.

CONCLUSION

A biophysical simulation model accurately predicts pCR and long-term outcomes from baseline MRI and clinical data, and is a promising tool to guide escalation/de-escalation of NAC.

Clinical trials of immunotherapy in triple-negative breast cancer

Purpose

Immunotherapy has started to transform the treatment of triple-negative breast cancer (TNBC), in part due to the unique immunogenicity of this breast cancer subtype. This review summarizes clinical studies of immunotherapy in advanced and early-stage TNBC.

Findings

Initial studies of checkpoint blockade monotherapy demonstrated occasional responses, especially in patients with untreated programmed death-ligand 1 (PD-L1) positive advanced TNBC, but failed to confirm a survival advantage over chemotherapy. Nonetheless, pembrolizumab monotherapy has tumor agnostic approval for microsatellite instability-high or high tumor mutational burden cancers, and thus can be considered for select patients with advanced TNBC. Combination chemoimmunotherapy approaches have been more successful, and pembrolizumab is approved for PD-L1 positive advanced TNBC in combination with chemotherapy. This success has been translated to the curative setting, where pembrolizumab is now approved in combination with neoadjuvant chemotherapy for high-risk early-stage TNBC.

Conclusion

Immunotherapy has been a welcome addition to the growing armamentarium for TNBC, but responses remain limited to a subset of patients. Innovative strategies are under investigation in an attempt to induce immune responses in resistant tumors—with regimens incorporating small-molecule inhibitors, novel immune checkpoint targets, and intratumoral injections that directly alter the tumor microenvironment. As the focus shifts toward the use of immunotherapy for early-stage TNBC, it will be critical to identify those who derive the most benefit from treatment, given the potential for irreversible autoimmune toxicity and the lack of predictive accuracy of PD-L1 expression in the early-stage setting.

Development and Validation of a Decision Analytical Model for Posttreatment Surveillance for Patients With Oropharyngeal Carcinoma

IMPORTANCE

Clinical practice regarding posttreatment radiologic surveillance for patients with oropharyngeal carcinoma (OPC) is neither adapted to individual patient risk nor fully evidence based.

OBJECTIVES

To construct a microsimulation model for posttreatment OPC progression and use it to optimize surveillance strategies while accounting for both tumor stage and human papillomavirus (HPV) status.

DESIGN, SETTING, AND PARTICIPANTS

In this decision analytical modeling study, a Markov model of 3-year posttreatment patient trajectories was created. The training data source was the American College of Surgeon's National Cancer Database from 2010 to 2015. The external validation data set was the 2016 International Collaboration on Oropharyngeal Cancer Network for Staging (ICON-S) study. Training data comprised 2159 patients with OPC treated with primary radiotherapy who had known HPV status and disease staging information. Patients with American Joint Committee on Cancer, 7th edition stage III to IVB disease and those with clinical metastases during the time of primary treatment were included. Data were analyzed from August 1 to October 31, 2020.

MAIN OUTCOMES AND MEASURES

Main outcomes included disease stage and HPV status, specific disease transition probabilities, and latency of surveillance regimens, defined as time between recurrence incidence and disease discovery.

RESULTS

Training data consisted of 2159 total patients (1708 men [79.1%]; median age, 59.6 years [range, 40-90 years]; 401 with stage III disease, 1415 with stage IVA disease, and 343 with stage IVB disease). Cohorts predominantly had HPV-negative disease (1606 [74.4%]). With model-optimized regimens, recurrent disease was discovered a mean of 0.6 months (95% CI, 0.5-0.8 months) earlier than with a standard surveillance regimen based on current clinical guidelines. Recurrent disease was discovered using the optimized regimens without significant reduction in sensitivity. Compared with strategies based on reimbursement guidelines, the model-optimized regimens found disease a mean of 1.8 months (95% CI, 1.3-2.3 months) earlier.

CONCLUSIONS AND RELEVANCE

Optimized, risk-stratified surveillance regimens consistently outperformed nonoptimized strategies. These gains were obtained without requiring any additional imaging studies. This approach to risk-stratified surveillance optimization is generalizable to a broad range of tumor types and risk factors.

Abstract P3-14-15: The impact of race and age on response to neoadjuvant therapy and long-term outcomes in black and white women with early-stage breast cancer

Background: Women diagnosed with breast cancer under the age of 40 years (yrs) have a poorer prognosis as compared to older women. While black women overall have a slightly lower incidence of developing breast cancer than white women, black women are twice as likely to develop breast cancer under 40 yrs as compared to white women. There are a paucity of data and an urgent need to evaluate response to neoadjuvant chemotherapy (NACT) and determine long-term outcomes in young black women with breast cancer.. Methods: We analyzed data from 2,196 black and white patients (pts) with early-stage (stages 1-3) breast cancer treated at the University of Chicago over the last two decades. Pts were divided into four groups: white women &lt;= 40 yrs (young white, n=235), black women &lt;= 40 years (young black, n=151), White women &gt;= 55 years (older white, n=982), and black women &gt;= 55 years (older black, n=828). Overall survival (OS) and recurrence free survival (RFS) were determined using Cox proportional hazards models that controlled for stage, tumor grade, subtype, and Carlson comorbidity index. Risk of recurrence was examined using the method by Fine and Gray, accounting for competing risk from non-recurrence death. Pathologic complete response rate (pCR, ypT0/isN0) was determined with logistic regression controlling for subtype, stage, and tumor grade.. Results: The cohort members were followed for a median of 81 months. Of the four groups, young black pts had the highest risk of recurrence, which was 22% higher than young white pts (p=0.43) and 76% higher than older black pts (p=0.008). These age/racial differences in recurrence rates were not statistically significant after adjusting for subtype, stage, and grade. In terms of overall survival, older black patients had the worst outcome. After adjusting for stage, grade, subtype and comorbidities, increased mortality in older black vs older white pts persisted (adjusted hazard ratio: 1.55, 95% CI: 1.23-1.96, p&lt;0.001). In the 397 pts receiving NACT, 37.3% of young white pts achieved a pCR, compared to 11.9% of young black pts. In older white and black pts, 24.6% and 26.2% achieved a pCR, respectively. After adjusting for subtype, grade, and stage, young black pts were still less likely to achieve a pCR as compared to young white pts (adjusted odds ratio: 0.41, 95% CI: 0.19-0.88, p=0.022).. Conclusions: Black pts with early-stage breast cancer had poorer outcomes compared to white pts. In general, older pts had poorer OS compared with younger pts, with older black pts having the poorest OS. Young white pts had the highest pCR rates, while young black pts had the lowest. Future studies will work to elucidate the underlying reasons driving these disparities in clinical outcomes, which disproportionately affect black women.

Citation Format: Elizabeth Terman, Jori Sheade, Fangyuan Zhao, Frederick M. Howard, Nora Jaskowiak, Jennifer Tseng, Olwen Hahn, Gini Fleming, Olufunmilayo I. Olopade, Dezheng Huo, Rita Nanda. The impact of race and age on response to neoadjuvant therapy and long-term outcomes in black and white women with early-stage breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-15.

The emerging role of immune checkpoint inhibitors for the treatment of breast cancer

INTRODUCTION

Breast cancer has traditionally been viewed as immunogenically 'cold,' but two immune checkpoint inhibitors have been approved in combination with chemotherapy for PD-L1 positive advanced triple-negative breast cancer (TNBC), and pembrolizumab was also recently approved for early stage TNBC. As the landscape is rapidly evolving, a comprehensive review of checkpoint inhibitors in breast cancer is needed to aid clinicians in selecting appropriate candidates for therapy, and to highlight ongoing promising studies in this area and topics in need of further investigation.

AREA COVERED

This review summarizes the latest evidence from completed and ongoing trials of immune checkpoint inhibitors. Ongoing studies were identified using a search of ClinicalTrials.gov with the term 'breast cancer' along with specific checkpoint inhibitor agents.

EXPERT OPINION

A number of novel combination strategies are under investigation to enhance response and overcome resistance to immunotherapy, with promising preliminary data from checkpoint inhibitors targeting TIGIT, combinations with small molecule inhibitors such as lenvatinib, and injectable agents directly influencing the immune microenvironment. As immunotherapy enters into the curative setting, biomarkers predictive of immunotherapy benefit are needed, as PD-L1 status has not been a helpful discriminator in completed trials in early-stage breast cancer.

The impact of site-specific digital histology signatures on deep learning model accuracy and bias

The Cancer Genome Atlas (TCGA) is one of the largest biorepositories of digital histology. Deep learning (DL) models have been trained on TCGA to predict numerous features directly from histology, including survival, gene expression patterns, and driver mutations. However, we demonstrate that these features vary substantially across tissue submitting sites in TCGA for over 3,000 patients with six cancer subtypes. Additionally, we show that histologic image differences between submitting sites can easily be identified with DL. Site detection remains possible despite commonly used color normalization and augmentation methods, and we quantify the image characteristics constituting this site-specific digital histology signature. We demonstrate that these site-specific signatures lead to biased accuracy for prediction of features including survival, genomic mutations, and tumor stage. Furthermore, ethnicity can also be inferred from site-specific signatures, which must be accounted for to ensure equitable application of DL. These site-specific signatures can lead to overoptimistic estimates of model performance, and we propose a quadratic programming method that abrogates this bias by ensuring models are not trained and validated on samples from the same site.

Lung-Protective Ventilation Over 6 Years at a Large Academic Medical Center: An Evaluation of Trends, Adherence, and Perceptions of Benefit

The main objective of this study was to evaluate trends in set tidal volumes across all adult ICUs at a large academic medical center over 6 years, with a focus on adherence to lung-protective ventilation (≤ 8-cc/kg ideal body weight). A secondary objective was to survey providers on their perceptions of lung-protective ventilation and barriers to its implementation.

DESIGN

Retrospective observational analysis (primary objective) and cross-sectional survey study (secondary objective), both at a single center.

PARTICIPANTS

Mechanically ventilated adult patients with a set tidal volume (primary objective) and providers rotating through the Medical and Neurosciences ICUs (secondary objective).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

From 2013 to 2018, the average initial set tidal volume (cc/kg ideal body weight) decreased from 8.99 ± 2.19 to 7.45±1.34 (p < 0.001). The cardiothoracic ICU had the largest change in tidal volume from 11.09 ± 1.96 in 2013 to 7.97 ± 1.03 in 2018 (p < 0.001). Although the majority of tidal volumes across all ICUs were between 6.58 and 8.01 (interquartile range) in 2018, 27% of patients were still being ventilated at volumes greater than 8-cc/kg ideal body weight. Most surveyed respondents felt there was benefit to lung-protective ventilation, though many did not routinely calculate the set tidal volume in cc/kg ideal body weight, and most did not feel it was easily calculable with the current electronic medical record system.

CONCLUSIONS

Despite a trend toward lower tidal volumes over the years, in 2018, over a quarter of mechanically ventilated adult patients were being ventilated with tidal volumes greater than 8 cc/kg. Survey data indicate that despite respondents acknowledging the benefits of lung-protective ventilation, there are barriers to its optimal implementation. Future modifications of the electronic medical record, including a calculator to set tidal volume in cc/kg and the use of default set tidal volumes, may help facilitate the delivery of and adherence to lung-protective ventilation.

Implementation of an automated scheduling tool improves schedule quality and resident satisfaction

Rotation schedules for residents must balance individual preferences, compliance with Accreditation Council for Graduate Medical Education guidelines, and institutional staffing requirements. Automation has the potential to improve the consistency and quality of schedules. We designed a novel rotation scheduling tool, the Automated Internal Medicine Scheduler (AIMS), and evaluated schedule quality and resident satisfaction and perceptions of fairness after implementation. We compared schedule uniformity, fulfillment of resident preferences, and conflicting shift assignments for the hand-made 2017–2018 schedule, and the AIMS-generated 2018–2019 schedule. Residents were surveyed in September 2018 to assess perception of schedule quality and fairness. With AIMS, 71/74 (96.0%) interns and 66/82 (80.5%) residents were assigned to their first-choice rotation, a significant increase from the 50/72 (69.4%) interns and 25/82 (30.5%) residents assigned their first-choice in the 2017–2018 academic year. AIMS also yielded significant improvements in the number of night shift/day shift conflicts at the time of rotation switches for interns, with a significant decrease to 0.3 conflicts per intern compared to 0.7 with the prior manual schedule. Twenty-two of 82 residents (27%) completed the survey, and average satisfaction and perception of fairness were 0.7 and 0.9 points higher on a 5-point Likert scale for the AIMS-generated schedule when compared to the non-AIMS schedule. There was no significant difference in the preference for assigned vacation blocks, or in variance for night or ICU rotations. Automated scheduling improved several metrics of schedule quality, as well as resident satisfaction. Future directions include evaluation of the tool in other residency programs and comparison with alternative scheduling algorithms.

Management of chronic pelvic pain

Chronic pelvic pain (CPP) is a common complaint of women presenting for gynecologic and primary care. Evaluation of CPP requires obtaining a careful history including not only obstetrical and gynecologic information but also screening for gastrointestinal, urologic, musculoskeletal, and neurological disorders. A detailed physical examination is also necessary. Management of CPP depends largely on the cause. Gynecologic causes include endometriosis, pelvic inflammatory disease, adhesive disease, pelvic congestion syndrome, ovarian retention syndrome, ovarian remnant syndrome, adenomyosis, and leiomyomas. Some non-gynecologic causes are interstitial cystitis/painful bladder syndrome, irritable bowel syndrome, pelvic floor tension myalgia, and abdominal myofascial pain syndrome. Treatments may be directed toward specific causes or may be targeted to general pain management. The most effective therapy may involve using both approaches. The diagnosis and treatment of each of the above disorders, and the management of CPP itself, is discussed.

Fracture of the acetabulum in a 14-year-old patient: 20-year review

A case report of 14-year old female with an acetabular fracture involving the anterior column and posterior column-posterior wall is presented here and the findings on 20-year follow-up are described.

Conscious pain mapping by laparoscopy in women with chronic pelvic pain

OBJECTIVE

To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain.

METHODS

Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales.

RESULTS

Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean +/- standard deviation visual analog scale pain levels were 8.7 +/- 1.2 preoperatively and 5.5 +/- 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free.

CONCLUSION

Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses.

Transcervical or intraperitoneal analgesia for laparoscopic tubal sterilization: a randomized controlled trial

OBJECTIVE

To test the effectiveness of analgesia administered transcervically through a uterine manipulator compared with direct topical application to the fallopian tubes for relief of postoperative pain after interval laparoscopic tubal sterilization.

METHODS

Sixty-one women who had laparoscopic sterilization were enrolled in a randomized, double-masked clinical trial comparing analgesia with 75 mg of bupivacaine administered through a uterine manipulator with 75 mg of bupivacaine applied directly to the fallopian tubes through a secondary trocar. Results were evaluated using visual analog scale pain levels, time of administration of analgesics, total analgesics required, and recovery room times. We calculated that a sample size of 60 women would detect a 30% difference in pain levels with a power of 80% at a significance level of .05.

RESULTS

In the 59 women who completed the study, there were no differences in the two groups in pain levels, amounts of medications used, or times to administration of postoperative analgesia. Mean recovery room time was shorter in the group given analgesia transcervically, but that difference was not statistically significant.

CONCLUSION

There were no significant differences in postoperative pain relief between transcervical administration and topical application of analgesia for laparoscopic tubal sterilization.

An evidence-based medicine approach to the treatment of endometriosis-associated chronic pelvic pain: placebo-controlled studies

OBJECTIVE

Use an evidence-based medicine (EBM) approach to evaluate the evidence regarding efficacy of treatment of endometriosis-associated chronic pelvic pain (CPP) in placebo-controlled randomized clinical trials (RCT).

DESIGN

Review of six randomized, controlled trials (Canadian Task Force classification I).

SETTING

University of Rochester School of Medicine and Dentistry. Patients. Three hundred eighty-one women with endometriosis enrolled in placebo-controlled randomized clinical trials. Intervention. A MEDLINE search of published medical articles from January 1976, to January 1998.

MEASUREMENTS AND MAIN RESULTS

Six placebo-controlled randomized clinical trials were found that addressed the treatment of pelvic pain associated with endometriosis and met validity criteria; one was a study of surgical treatment, two of medical therapies, and three of combined surgical and medical treatments. They clearly show that laparoscopic surgery and medical treatment with medroxyprogesterone acetate, danazol, or nafarelin are more effective than placebo. Evidence for efficacy of leuprolide acetate is weaker. At 6 months, absolute decreases in pain scores are quite similar with surgical or medical treatment. Medical therapy after surgical treatment significantly reduced pain, but six months after it was stopped there was no difference between women treated and not treated postoperatively.

CONCLUSIONS

Although either surgical or medical treatment of endometriosis in women with CPP is clearly indicated, pain relief of 6 or more months' duration can be expected in only 40 to 70% of women with endometriosis-associated CPP.

The role of laparoscopy as a diagnostic tool in chronic pelvic pain

More than 40% of laparoscopies are performed for the diagnosis of chronic pelvic pain (CPP). Although laparoscopic evaluation is sometimes considered a routine part of the evaluation, ideally the decision to perform a laparoscopy should be based on the patient's history, physical examination and findings of non-invasive tests. About 65% of women with CPP have at least one diagnosis detectable by laparoscopy and it is common to attribute causality to this diagnosis. Endometriosis is diagnosed in one-third of laparoscopies for CPP. Endometriosis requires histological confirmation to assure an accurate diagnosis. Adhesions are diagnosed in about one-quarter of laparoscopies. Ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, post-operative peritoneal cysts and endosalpingiosis are other diagnoses that can be made laparoscopically in some cases. Laparoscopic conscious pain mapping has the potential to improve the accuracy of laparoscopy as a diagnostic tool in CPP.

A randomized, controlled trial of a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circumcision

OBJECTIVE

We set out to compare a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) to dorsal penile nerve block with lidocaine for anesthesia during circumcision.

STUDY DESIGN

In a double-blind study, term newborns were randomized to local anesthetic cream and sodium chloride solution dorsal penile nerve block (n = 31) or to placebo cream and lidocaine dorsal penile nerve block (n = 29). Pain was assessed by determination of heart rate, respiratory rate, and behavioral distress scoring. Group differences were evaluated with repeat-measures analyses of variance.

RESULTS

Distress scores and heart rates were significantly higher in the eutectic mixture group than in the lidocaine group. Respiratory rates were higher in the eutectic mixture group but did not reach statistical significance.

CONCLUSIONS

Distress scores and heart rates were significantly higher in infants treated with the anesthetic mixture than in infants treated with lidocaine. Dorsal penile nerve block with lidocaine is a more efficacious means of providing anesthesia for neonatal circumcision than the mixture of local anesthetics.

Physiologic stability of newborns during cup- and bottle-feeding

BACKGROUND

To prevent breastfeeding problems, cup-feeding has been recommended as a method of providing medically necessary supplemental feedings to breastfed infants.

OBJECTIVES

To compare amounts ingested, administration time, and infant physiologic stability during cup-, bottle-, and breastfeeding.

DESIGN/METHODS

A total of 98 term, healthy newborns were randomized to either cup-feeding (n = 51) or bottle-feeding (n = 47). The heart (HR), respiratory (RR), and oxygen (O(2)) saturation rates were monitored on these infants and 25 breastfed newborns during 1 feeding. Differences in amounts ingested and administration times were evaluated with t tests and physiologic data with repeat measures analysis of variance.

RESULTS

There were no significant differences in administration time, amounts ingested or overall HR, RR, and (O(2)) saturation rates, between cup and bottle groups. Breastfed infants had longer administration times and lower overall HR, RR, and higher O(2) saturation as compared with cup- and bottle-fed infants.

CONCLUSIONS

Administration times, amounts ingested, and infant physiologic stability do not differ with cup- and bottle-feeding. Breastfeeding takes longer than cup- or bottle-feeding, but infants experience less physiologic variability. These data support cup-feeding as an alternative to bottle-feeding for supplying supplements to breastfed infants.

Operative laparoscopic treatment of ovarian retention syndrome

STUDY OBJECTIVE

To evaluate the ability to treat ovarian retention syndrome (ORS) by operative laparoscopy.

DESIGN METHODS

Retrospective observational analysis (Canadian Task Force classification II-2).

SETTING

Pelvic pain referral practice in an university-affiliated community hospital.

PATIENTS

Thirty consecutive women with ORS.

INTERVENTION

Operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Salpingo-oophorectomy or oophorectomy was completed laparoscopically in 26 women; conversion to laparotomy was necessary in 4 (13.3%). Mean operating time was 159 +/- 63 minutes, mean blood loss was 119 +/- 152 ml, and mean hospital stay was 1.1 +/- 1.4 days. Complications occurred in four patients (13. 3%); in two (6.6%) they were intraoperative. The mean time interval between hysterectomy and symptoms of ORS was 6.4 +/- 4.6 years. Mean preoperative duration of pain was 40.11 +/- 41.3 months. Of 27 patients with adequate follow-up, 13 (48%) were pain free postoperatively with a mean follow-up of 12.9 +/- 8.2 months. Fourteen women (52%) had recurrent pain with mean time to recurrence of 8.8 +/- 10 months. Mean visual analog pain scores were 7.5 +/- 2. 4 preoperatively and 2.3 +/- 3.1 postoperatively (p <0.001). Endometriosis at time of surgery was associated with a significantly higher risk of recurrent pelvic pain (relative risk = 2.3, 95% confidence intervals 1.1, 5.1). Ovarian preservation was significantly related to recurrence of pain (RR = 2.6, 95% CI 1.52, 4.53) and risk of repeat surgery (RR = 4.4, 95% CI 1.69, 11.33).

CONCLUSIONS

Ovarian retention syndrome can usually be treated by laparoscopy. Removal of both ovaries, if present, may be necessary to prevent recurrent pain. In our series, 48% of women experienced prolonged relief. (J Am Assoc Gynecol Laparosc 6(3):297-302, 1999)

A survey of gynecologists' attitudes regarding decision making in the management of non-cancerous conditions that frequently result in hysterectomy

OBJECTIVE

To explore attitudes of practicing gynecologists regarding making treatment decisions for patients with benign uterine conditions frequently treated with hysterectomy.

DESIGN

Mailed survey.

PARTICIPANTS

66 gynecologists practicing in the Greater Rochester, New York, area.

INTERVENTIONS

After reading brief vignettes, respondents indicated how they would treat patients with chronic pelvic pain, uterine leiomyomas, and abnormal uterine bleeding, and rated the importance of 24 considerations in making their treatment decisions on a 1-to-5 scale ranging from not important to extremely important.

RESULTS

Fourteen considerations (58%) had group mean importance ratings higher than 3. Exploratory factor analysis identified four factors that accounted for 96% of the variance. Respondent gender, practice type, graduation from a U.S. vs a non-U.S. medical school, and opinion regarding roles of doctor and patient in making treatment decisions were associated with significant differences in factor scores.

CONCLUSIONS

Gynecologists' attitudes toward hysterectomy decisions are complex, multifactorial, and variable. Depending on the extent to which these attitudes affect treatment decisions, differences among gynecologists in their clinical decision making processes could account for a substantial amount of the regional variability in hysterectomy use.

The effects of early pacifier use on breastfeeding duration

OBJECTIVE

To evaluate the effects of pacifier use and the timing of pacifier introduction on breastfeeding duration, problems, and frequency.

METHODS

A cohort of 265 breastfeeding mother-infant dyads was followed prospectively. Maternal interviews were conducted at delivery, 2, 6, 12, and 24 weeks, and thereafter every 90 days until breastfeeding ended. Information was obtained regarding pacifier use, infant feeding, use of supplemental foods and breastfeeding frequency, duration, and problems. The effect of pacifier introduction by 6 weeks of age on breastfeeding duration was evaluated with Kaplan-Meier and Cox proportional hazards models. The effect of the timing of pacifier introduction (</=2 weeks and </=6 weeks) on breastfeeding duration at 2 and 3 months was evaluated using logistic regression modeling.

RESULTS

A total of 181 mothers (68%) introduced a pacifier before 6 weeks. In adjusted analyses, pacifier introduction by 6 weeks was associated with a significantly increased risk for shortened duration of full (hazard ratio, 1.53; 95% confidence interval: 1.15, 2.05) and overall (hazard ratio, 1.61; 95% confidence interval: 1.19,2.19) breastfeeding. Women who introduced pacifiers tended to breastfeed their infants fewer times per day, with significant differences noted at 2 (8.1 +/- 2.6 vs 9.0 +/- 2.3) and 12 weeks' (6.3 +/- 2.0 vs 7.4 +/- 1.6) postpartum. At 12 weeks postpartum, women who introduced pacifiers also were more likely to report that breastfeeding was inconvenient and that they had insufficient milk supplies. Pacifier use begun either before 2 weeks or before 6 weeks' postpartum was not significantly associated with breastfeeding duration at 2 and 3 months.

CONCLUSIONS

Pacifier use was independently associated with significant declines in the duration of full and overall breastfeeding. Breastfeeding duration in the first 3 months' postpartum, however, was unaffected by pacifier use. Women who introduced pacifiers tended to breastfeed their infants less frequently and experienced breastfeeding problems consistent with infrequent feeding. Findings from this study suggest that the decreases in breastfeeding duration associated with pacifier use may be a consequence of less frequent breastfeeding among women who introduce pacifiers to their infants.

Hereditary form of parkinsonism--dementia

In four generations of a family, 13 members were afflicted with an autosomal dominant disorder characterized by young age at onset, early weight loss, and rapidly progressive dopa-responsive parkinsonism, followed later by dementia and, in some, by hypotension. Intellectual dysfunction began with subjective memory loss and objective visuospatial dysfunction and was followed later by decline of frontal lobe cognitive and memory functions. Neuropathological examination in 4 autopsied cases showed neuronal loss in the substantia nigra and locus ceruleus and widespread Lewy bodies, many of them in the cerebral cortex; those in the hypothalamus and locus ceruleus were often of bizarre shapes. Other findings were vacuolation of the temporal cortex, unusual neuronal loss and gliosis in the hippocampus (CA 2/3), and neuronal loss in the nucleus basalis. There were no neuritic plaques, neurofibrillary tangles, or amyloid deposits. Positron emission tomography in 3 patients showed decreased striatal uptake of fluorodopa. Neurochemical analysis of an autopsied brain showed a pronounced decrease in choline acetyltransferase activity in the frontal and temporal cortices and hippocampus and a severe depletion of striatal dopamine with a pattern not typical of classic Parkinson's disease.

Neonatal circumcision and pain relief: current training practices

OBJECTIVE

We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure.

METHODS

Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%).

RESULTS

Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties.

CONCLUSIONS

Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Management of tubal prolapse after hysterectomy

Uterine tube prolapse into the vaginal vault is an uncommon complication after hysterectomy, and our 6 patients bring to 90 the number of cases reported in the literature. Symptoms consist almost exclusively of vaginal bloody discharge and/or leukorrhea, persistent pelvic pain, and dyspareunia. Surgical treatment must be individualized according to the patient's symptoms. In our series, sexually active women with pelvic pain and dyspareunia had the best outcome when a combined laparoscopic and vaginal approach was used.

Reaction of residents to a teaching collaborative practice

Using the team concept, certified nurse-midwives, nurse practitioners, and physician assistants help educate physicians in an obstetrics and gynecology residency program and help to create a balance between education and service. This program is well received by the physicians in graduate medical education, and the majority indicate they will work within a collaborative model of practice.

Laparoscopic lateral ovarian transposition before radiation treatment of Hodgkin disease

More than one-half of women treated with pelvic radiation therapy for malignant disease experience premature ovarian failure. Preservation of ovarian function by repositioning the ovaries out of the irradiation field is suggested in all women of reproductive age. This repositioning generally is done by moving the ovaries either medially so they are posterior to the uterus, or laterally so they are in the paracolic gutters. Laparoscopic medial transposition has been reported, with mixed results. A woman underwent successful laparoscopic lateral transposition before irradiation for stage IIIa Hodgkin disease. A review of published cases suggests that this is preferable to medial transposition.

Direct laparoscopic cannula insertion at the left upper quadrant

We evaluated the efficacy and safety of direct left upper quadrant (LUQ) cannula insertion for laparoscopic surgery in 23 women with prior pelvic surgery, compared with direct umbilical cannula insertion in a control group of 81 patients. Generally, the laparoscope was retained at the LUQ site throughout the operative procedure. Cannula insertions at the LUQ were successful in the first attempt in 22 patients, compared with a single successful attempt in 78 of 81 umbilical insertions. Nine women had anterior abdominal wall adhesions that extended to the umbilical area. Seven had either a prior midline (1) or Pfannenstiel (6) incision; all seven had direct LUQ cannula insertions. Two patients with umbilical adhesions had no prior surgery. Of the three complications, two were related to cannula insertions and both were in the control group. There were no bowel injuries. More experience is required to prove that LUQ cannula insertion accomplishes its intended aim of avoiding bowel or omental injuries due to adhesions in women with prior abdominopelvic surgery, but initial results were favorable.