The Importance of Multi-Parametric MRI, PET/CT, and Biopsy for Identifying and Delineating the Extent of Locally Radiorecurrent Prostate Cancer: A Multi-institutional Analysis of the F-SHARP Clinical Trial

PURPOSE/OBJECTIVE(S)

Up to 50% of clinical recurrences after curative-intent radiation are intraprostatic local radiorecurrences (LRR), with improved detection through the recent incorporation of multi-parametric MRI and PET/CT in workup. Salvage local therapy (SLT) is increasingly being offered, particularly focal SLT to try to reduce toxicity due to prior radiation. Limited data exist on the incremental value of each imaging modality and biopsy in defining LRR. The objective of this study is to compare the findings of MRI, PET/CT and biopsy in patients with LRR prostate cancer, and the impact each modality has on identifying recurrence and defining the extent of prostate involvement.

MATERIALS/METHODS

This is a secondary analysis of 58 patients enrolled on the ongoing F-SHARP phase I/II clinical trial of salvage HDR brachytherapy from 3 institutions who underwent PSMA or fluciclovine PET/CT, MRI, and biopsy prior to enrollment. Recurrent tumor was delineated on each imaging modality and by inclusion of involved regions on biopsy. Descriptive statistics were used to compare the imaging-defined tumor with biopsy findings to assess the congruence between the imaging modalities and generate the percentage of patients with disease involvement on biopsy outside of the image-defined targets.

RESULTS

Initial therapy was conventional/moderately hypofractionated photons in 35 patients, LDR in 13, proton therapy in 7, SBRT in 2, and neutrons in 1. Recurrence Gleason grade groups included 1 (n = 3), 2 (17), 3 (12), 4 (8), 5 (9), and uninterpretable (9). MRI/TRUS sextant + fusion biopsy was performed in 40 patients, TRUS saturation biopsy in 4, and TRUS systematic biopsy in 14. The median number of cores involved and obtained were 6 and 14. The median number of discrete lesions on biopsy in different quadrants of the prostate was 3 (1-6). The median number of discrete lesions seen on MRI was 1 (0-4). MRI did not identity a discrete lesion in 4 patients. The sensitivity of MRI for detection of the LRR was 92.8%. The false negative rate for not detecting the focus of LRR on MRI was 7.2%. 68.4% of patients had biopsy-proven cancer outside of the MRI-defined target. Fluciclovine PET/CT was used in 45 patients, and 13 had PSMA PET/CT. The median number of lesions on PET/CT was 1 (0-2). PET/CT did not identify a discrete lesion in 8 patients. The pooled sensitivity of PET/CT in detecting the focus of LRR was 86.2% (Fluciclovine: 82.2%, PSMA: 100%). PET/CT false negative rate of PET/CT for not detecting the focus of LRR was 13.8% (Fluciclovine: 17.8%, PSMA 0%). 72.41% of patients had biopsy-proven cancer outside of the PET/CT-defined target (Fluciclovine: 77.8%, PSMA: 53.8%).

CONCLUSION

Although mpMRI and PET/CT are valuable tools for identifying LRR and delineating the extent of prostate/SV involvement, a thorough biopsy is mandatory if pursuing focal SLT. Such treatment should optimally be performed on a clinical trial with robust integration of all imaging and histopathologic data.

Tumor-Myeloid Cell Crosstalk Pathways Associated with Abscopal Responses in Breast Cancer

PURPOSE/OBJECTIVE(S)

To identify predictive biomarkers for combined radiotherapy (RT) and immune checkpoint inhibitor (ICI) therapy, which can induce systemic anti-tumor immune responses (i.e., "abscopal" responses) in breast cancer.

MATERIALS/METHODS

Four Trp53-/- Balb/c breast cancer syngeneic allograft models with low tumor mutational burden and resistance to dual ICI (anti-PD1 and anti-CTLA4, BioXcell) were used. Two lines exhibited abscopal responses to RT (8Gyx3) plus ICI combination therapy (i.e., "abscopal models"), whereas the other two did not (i.e., "non-abscopal models"). We performed spatial transcriptomics analysis (GeoMx whole transcriptome assay) of pan-cytokeratin positive (panCK+) tumor and tumor-adjacent CD45+ immune cell segments in orthotopically implanted tumors 10 days after initiating treatment with IgG control, RT alone, ICI alone, or RT/ICI combination (N>5 per group). Genes selectively induced by RT/ICI in panCK+ and CD45+ segments in abscopal models and were not induced in non-abscopal models were identified using two-tailed t-tests and FDR correction for multiple testing (FDR<5%). In vitro analyses of RT-induced secreted inflammatory signaling were conducted by exposing supernatant from irradiated (8Gy) tumor cells to a RAW264.7 macrophage cell line expressing an interferon-inducible luciferase reporter construct, followed by luciferase signal quantification (Invivogen).

RESULTS

Hierarchical clustering of immune-related genes in CD45+ immune segments from breast cancer models with abscopal responses to RT/ICI revealed global differences in tumor-adjacent immune profiles at baseline and after RT/ICI treatment. Abscopal responsive breast cancer models at baseline showed an enrichment of myeloid cell subtypes expressing complement protein C1q, Ccl8, and Csf1r in tumor-adjacent CD45+ immune cells, and CD8+ T cells expressing Ccl5. 10 days after treatment with RT/ICI, tumor-adjacent CD45+ immune cells in abscopal models were enriched in Cxcl10, Irf7, and FcgRIV, whereas these genes were not induced in non-abscopal models. CyTOF analyses confirmed the induction of inflamed professional antigen presenting cells (CD11c+CD80+IA/IE+) by RT/ICI in abscopal models. Within panCK+ tumor segments, RT/ICI in abscopal models selectively induced Isg15 and Zbp1, both of which are involved in secreted inflammatory signaling. Consistently, RT-induced secreted inflammatory signaling from tumor cells to macrophages evaluated in vitro was significantly greater in abscopal models compared to non-abscopal models.

CONCLUSION

Breast cancer models with abscopal responses to RT/ICI show increased Isg15- and Zbp1-dependent secreted inflammatory crosstalk that activates Cxcl10 and Irf7 expression in tumor-adjacent myeloid cells, which warrants further investigation as a potential predictive biomarker for combined RT/ICI therapy in breast cancer.

BRAND – exploring transverse polarization of electrons emitted in neutron decay

Neutron and nuclear beta decay correlation coefficients are sensitive to the exotic scalar and tensor interactions that are not included in the Standard Model (SM). The proposed experiment BRAND will measure simultaneously seven neutron correlation coefficients: H, L, N, R, S, U and V that depend on the transverse electron polarization – a quantity which vanishes in the SM. Five of these correlations: H, L, S, U and V were never attempted experimentally before. The expected impact of the proposed experiment is comparable to that of frequently measured “traditional” correlation coefficients (a, b, A, B, D) but offers completely different systematics and additional sensitivity to imaginary parts of the scalar and tensor couplings. In order to demonstrate the feasibility of the challenging techniques such as the event-by-event decay kinematics reconstruction together with the electron polarimetry a test setup was installed at the cold neutron beam line PF1B at the Laue-Langevin Institute, Grenoble, France. In this contribution, the results of the first run as well as plans for the run in Autumn 2021 will be discussed.

Detectable Post-operative Circulating Tumor Human Papillomavirus (HPV) DNA And Association with Recurrence in Patients with HPV-Associated Oropharyngeal Squamous Cell Carcinoma

PURPOSE

  To determine the rate of detectability of ctHPVDNA after surgery but before adjuvant therapy in patients with HPV-associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) and to investigate whether detectable ctHPVDNA at this time point may be associated with risk of recurrence.

METHODS AND MATERIALS

 Prospectively collected samples from patients with OPSCC were examined in a blinded fashion using a multi-analyte PCR assay. 45 samples were collected from HPV(+)OPSCC patients pre-op (prior to any treatment), and 159 samples post-op (before or at the start of adjuvant RT). Samples were identified via the radiation oncology biobank or via participation in a clinical trial. RT consisted of 60 Gy +/- cisplatin or de-escalation (30 Gy to 36 Gy in 20 b.i.d. fractions + docetaxel). 32 patients had paired samples available pre and post-op for the primary analysis. Additional exploratory analyses including associations of patient and tumor characteristics with recurrence were assessed using Cox proportional hazards models for all 159 post-op samples.. Detectability of ctHPVDNA was compared across groups utilizing logistic regression. Estimates of recurrence free survival (RFS) were made using Kaplan-Meier (KM).

RESULTS

In a paired analysis of 32 pre and post-op timepoints, 94% of patients had detectable ctHPVDNA pre-op and 41% post-op. RFS at 18 months was 83% (95% CI: 47-95%) for patients with detectable post-op ctHPVDNA compared to 100% for patients with undetectable post-op ctHPVDNA (p=.094).In an exploratory analysis of non-paired post-op samples, ctHPVDNA was detectable in 26% (41 of 159) of patients (median of 22 days post-op). Age (1.06, p=0.025), LVSI (OR 3.17, p=0.011) and ENE (OR=5.67, p=0.001) were associated with detectable ctHPVDNA after surgery. Detectable post-op ctHPVDNA was significantly associated with RFS (p<0.001).

CONCLUSION

Amongst patients with detectable pre-op ctHPVDNA, a significant proportion have detectable post-op ctHPVDNA in paired post-op samples, collected prior to the initiation of adjuvant radiation therapy. Future prospective study is warranted to investigate the association of detectable post-op ctHPVDNA with recurrence, including in comparison to established clinical and pathologic risk factors.

Immunotherapy for Alzheimer's Disease: Current Scenario and Future Perspectives

Alzheimer's disease (AD) is a global health concern owing to its complexity, which often poses a great challenge to the development of therapeutic approaches. No single theory has yet accounted for the various risk factors leading to the pathological and clinical manifestations of dementia-type AD. Therefore, treatment options targeting various molecules involved in the pathogenesis of the disease have been unsuccessful. However, the exploration of various immunotherapeutic avenues revitalizes hope after decades of disappointment. The hallmark of a good immunotherapeutic candidate is not only to remove amyloid plaques but also to slow cognitive decline. In line with this, both active and passive immunotherapy have shown success and limitations. Recent approval of aducanumab for the treatment of AD demonstrates how close passive immunotherapy is to being successful. However, several major bottlenecks still need to be resolved. This review outlines recent successes and challenges in the pursuit of an AD vaccine.

Developments and challenges in dermatology: an update from the Interactive Derma Academy (IDeA) 2019

The 2019 Interactive Derma Academy (IDeA) meeting was held in Lisbon, Portugal, 10-12 May, bringing together leading dermatology experts from across Europe, the Middle East and Asia. Over three days, the latest developments and challenges in relation to the pathophysiology, diagnosis, evaluation and management of dermatological conditions were presented, with a particular focus on acne, atopic dermatitis (AD) and actinic keratosis (AK). Interesting clinical case studies relating to these key topics were discussed with attendees to establish current evidence-based best practices. Presentations reviewed current treatments, potential therapeutic approaches and key considerations in the management of acne, AK and AD, and discussed the importance of the microbiome in these conditions, as well as the provision of patient education/support. It was highlighted that active treatment is not always required for AK, depending on patient preferences and clinical circumstances. In addition to presentations, two interactive workshops on the diagnosis and treatment of sexually transmitted infections/diseases (STIs/STDs) presenting to the dermatology clinic, and current and future dermocosmetics were conducted. The potential for misdiagnosis of STIs/STDs was discussed, with dermoscopy and/or reflectance confocal microscopy suggested as useful diagnostic techniques. In addition, botulinum toxin was introduced as a potential dermocosmetic, and the possibility of microbiome alteration in the treatment of dermatological conditions emphasized. Furthermore, several challenges in dermatology, including the use of lasers, the complexity of atopic dermatitis, wound care, use of biosimilars and application of non-invasive techniques in skin cancer diagnosis were reviewed. In this supplement, we provide an overview of the presentations and discussions from the fourth successful IDeA meeting, summarizing the key insights shared by dermatologists from across the globe.

Cerebral Venous Thrombosis in COVID-19: A New York Metropolitan Cohort Study

BACKGROUND AND PURPOSE

Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area.

MATERIALS AND METHODS

We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020.

RESULTS

Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36-62 years; range, 17-95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%.

CONCLUSIONS

Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.

Comparative study of caregiver stress between patients of obsessive compulsive disorder and chronic medical illness, without any physical disability

Introduction

Obsessive compulsive disorder (OCD) is a disabling condition that affects the quality of life of both the patient and the caregivers. Similarly, in patients with physical medical illness, caregivers face a significant amount of stress.

Objectives

This study aimed to assess and compare the caregiver strain index between patients of OCD and medical illness. Moreover, this study will also compare the care giver strain index in the patients of OCD and physical medical illness depending on the severity and duration of the illness.

Methods

Study was done at Department of psychiatry, Teerthanker Mahaveer University, Moradabad. In this Cross-sectional study 2 groups of caregivers were included. The group 1 included 30 caregivers of obsessive compulsive disorder patients and group 2 included 30 caregivers for physical medical illness. The Yale-Brown Obsessive Compulsive Scale was used for measuring the severity of OCD and the stress in caregivers were drawn from Caregiver strain index.

Results

This study reported a high objective burden among caregivers of OCD compared with the physical medical illness (P-value=0.002). The age of the caregivers also showed to be significantly associated with the stress in both the groups. The severity of the OCD was shown to be correlated well with the stress of the caregivers (P-value=0.032). In contrast, in physical medical illness the duration of the disease showed no significant association with the caregiver’s stress.

Conclusions

This study showed that in patients with OCD caregivers face a higher strain compared with the physical medical illness.

Disclosure

No significant relationships.

DAVI: Deep learning-based tool for alignment and single nucleotide variant identification

Next-generation sequencing (NGS) technologies have provided affordable but errorful ways to generate raw genetic data. To extract variant information from billions of NGS reads is still a daunting task which involves various hand-crafted and parameterized statistical tools. Here we propose a deep neural networks (DNN) based alignment and single nucleotide variant (SNV) identifier tool known as DAVI: deep alignment and variant identification. DAVI consists of models for both global and local alignment and for variant calling. We have evaluated the performance of DAVI against existing state-of-the-art tool sets and found that its accuracy and performance is comparable to existing tools used for bench-marking. We further demonstrate that while existing tools are based on data generated from a specific sequencing technology, the models proposed in DAVI are generic and can be used across different NGS technologies as well as across different species. The use of DAVI will therefore help non-human sequencing projects to benefit from the wealth of human ground truth data. Moreover, this approach is a migration from expert-driven statistical models to generic, automated, self-learning models.

0911 Association Between Chromosomal Abnormality And Sleep Disordered Breathing Characteristics In Children With Prader Willi Syndrome

Introduction

Prader-Willi Syndrome (PWS) is a genetic disorder caused by lack of expression of paternal genes from the chromosomal region 15 q11.2-q13. PWS is associated with excessive daytime sleepiness, sleep-disordered breathing (SDB), hypoventilation and circadian rhythm disturbance. Chromosomal deletion and uniparental disomy (UPD) are the two most common genetic etiologies of PWS. Differences in clinical features between these groups are recognized; however, limited literature exists regarding sleep characteristics.

Methods

The objective was to evaluate sleep characteristics of children with PWS between those with 15q11.2-q13 chromosomal deletion and those with other genetic etiologies. A retrospective chart review of in-laboratory polysomnograms (PSG) in children with PWS prior to growth hormone treatment was performed. The apnea hypopnea index (AHI), REM AHI, NREM AHI, Obstructive Apnea Index (OAI), Central Apnea Index (CAI), hypopnea index, arousal index, presence of hypoventilation, and positional AHI were assessed.

Results

Overall 33 PWS children were identified. Mean age was 5.9 ± 5.19 (range 1-16 years), 57% were male and 85% had SDB. Almost half (42%) had a 15q11.2-q13 chromosomal deletion. Of those without deletion, 30% had UPD. Sleep variables were similar in PWS with and without deletion: AHI (5.9±5.7 vs. 8.54±7.1; p=0.27), NREM AHI (3.3±4.6 vs. 6.2±6.3; p=0.16), CAI (1.1±1.5 vs. 1.9±3.8; p=0.43) SpO2 nadir 82.7±9.9% vs. 85.3±5.7%; p=0.36) and arousal index (10.3±7.8 vs. 15.4±7.8; p=0.09).

Conclusion

Sleep characteristics do not appear to clearly differ between genetic etiologies of PWS. Larger sample sizes are needed to support these findings.

Support

 

Thermal neutron-induced γ-ray background in 124Sn

The thermal neutron-induced gamma-ray background in ¹²⁴Sn is investigated in connection with neutrinoless double beta decay (0νββ) studies in ¹²⁴Sn. For this purpose, a 99.26% enriched ¹²⁴Sn sample was irradiated with a thermal neutron fluence of 3×10¹⁵/cm² in the Dhruva reactor at the Bhabha Atomic Research Centre, Mumbai. The gamma ray spectra of the irradiated sample were measured in a low background counting setup to study both long-lived and short-lived activities. The present data give an independent measurement of the half-life of ¹²⁵Sn*(32⁺) and ¹²⁵Sn(112^-) as 10.01(8) min and 9.63(2) d, respectively. The impact of the observed high-energy gamma rays and the residual activity due to ¹²⁵Sb, on the background in the region of interest around the Q_ββ value of ¹²⁴Sn (~2.291 MeV) is discussed.

Penile Paget's Disease: A Case Report and Review of the Literature

Extramammary Paget's Disease (EMPD) is a rare cutaneous, slow growing, intraepithelial adenocarcinoma that can be either primary (intraepithelial arising within the epidermis) or secondary (intraepithelial spread of a visceral carcinoma). Here we present the case of a 63-year-old male with EMPD of the glans penis stemming from underlying urothelial carcinoma. Our treatment decision elected for management with chemotherapy and local treatment with radiation therapy. Subsequent, review of the literature demonstrated a rare disease with a variety of underlying malignancies causing this secondary pathology. Caregivers should be aware of the association of Paget's disease and urothelial cancer and should have a high index of suspicion that erythematous penile lesions may represent Paget's disease and that penile biopsies should be performed early in this setting.

Study of the effect of external noise pickups on the performance of a cryogenic bolometer

This paper reports the detailed noise characterization, investigation of various noise sources, and its mitigation to improve the performance of a cryogenic bolometer detector for the TIN.TIN experiment. The noise spectrum has been measured for a sapphire bolometer test setup with an indigenously developed neutron transmutation doped Ge sensor in the cryogen free dilution refrigerator system at Mumbai. The effect of external noise, arising either from ground loops in the system or from the diagnostic and control electronics of the cryostat, on the performance of the bolometer is assessed. A systematic comparison of the influence of different noise pickups on the bolometer resolution is also presented. The best-achieved resolution (σ_E) at 15 mK is ∼15 keV for heater pulses and appears to be mainly limited by the noise due to the pulse tube cryocooler.

Evaluation of two histological classifications for actinic keratoses - PRO classification scored highest inter-rater reliability

BACKGROUND

Actinic keratoses (AKs) can histologically be classified by the extent of atypical keratinocytes throughout the epidermis or their pattern of basal proliferation. Currently, no data on the inter-rater reliability of both scores is available.

OBJECTIVE

To evaluate the inter-rater reliability of the two classification schemes; histological grade (AK I-III) and basal proliferation (PRO I-III).

METHODS

Histological images of 54 AKs were classified by 21 independent dermatopathologists with regard to basal proliferation (PRO I-III), histological grade (AK I-III) and assumed risk of progression into invasive carcinoma.

RESULTS

Overall, of the 54 AKs 16.7% (9/54) were classified as AK I, 66.7% (36/54) as AK II, and 16.7% (9/54) as AK III. With regards to basal growth pattern, 25.9% (14/54) were classified as PRO I, 42.6% (23/54) as PRO II, and 31.5% (17/54) as PRO III. We observed a highly significant inter-rater reliability for PRO-grading (P < 0.001) which was higher than for AK-grading (Kendall's W coefficient: AK = 0.488 vs. PRO = 0.793). We found substantial agreement for assumed progression risk for AKs with worsening basal proliferation (k = 0.759) compared to moderate agreement (k = 0.563) for different AK-gradings.

CONCLUSIONS

Histological classification of basal growth pattern (PRO) showed higher inter-rater reliability compared to the established classification of atypical keratinocytes throughout epidermal layers. Moreover, experienced dermatopathologists considered basal proliferation to be more important in terms of progression risk than upwards directed growth patterns. It should be considered to classify AKs according to their basal proliferation pattern (PRO I-III).

Abstract OT2-04-04: Multi-institution phase II trial of intraoperative electron beam radiotherapy boost at the time of breast conserving surgery with oncoplastic reconstruction in women with early-stage breast cancer

Background: In women amenable to breast conserving therapy, lumpectomy followed by adjuvant whole breast irradiation (WBI) remains the standard of care. Randomized trials demonstrate that addition of a lumpectomy cavity boost significantly reduces the risk of ipsilateral breast tumor recurrences but also increases the risk of breast fibrosis. Contemporary randomized trials define the lumpectomy cavity boost volume as a 1.7 cm isometric expansion on the lumpectomy cavity as delineated on CT. However, identifying the lumpectomy cavity can be challenging, especially in women that receive adjuvant chemotherapy and in cases in which surgical clips are not present. Recently, the use of oncoplastic techniques in breast conserving surgery has increased. These techniques are used to prevent the poor cosmetic results that can occur when a large volume of breast tissue is resected. Women that undergo oncoplastic reconstruction represent especially difficult cases for lumpectomy cavity delineation. Retrospective series have evaluated the use of intraoperative electron radiotherapy (IOERT) as a boost prior to WBI in women receiving lumpectomy without oncoplastic reconstruction. In the largest series of IOERT boost prior to WBI the local control rate of this approach was &gt;99%. Prospective data regarding IOERT boost in women undergoing oncoplastic reconstruction are limited. The advantages of this approach include direct visualization/irradiation of the tumor bed, sparing the skin of irradiation, and reducing the treatment time by ˜1 week. We hypothesize that IOERT boost followed by WBI will result in acceptably low rates of grade 3 fibrosis in women undergoing lumpectomy with oncoplastic reconstruction.

Trial Design: This is a single-arm, prospective study to evaluate the safety, toxicity and efficacy of IOERT boost at the time of breast conserving surgery in women with early-stage breast cancer undergoing oncoplastic reconstruction. Eligible women will receive 1 dose of 8 Gy to the surgical bed after lumpectomy but prior to oncoplastic reconstruction. Women will then receive adjuvant WBI of 40 Gy in 15 fractions or 50 Gy in 25 fractions.

Eligibility: Key criteria include age≥18 yo, clinically node-negative stage I/II, any breast cancer subtype.

Specific Aims: To determine the rate of grade 3 breast fibrosis at 1 year. Additional aims include surgical complication rates, cosmesis, and local regional cancer control.

Statistical Methods: Safety will be evaluated by the rate of surgical complications necessitating hospital readmission or return to the operating room within 30 days of surgery+IOERT. If ≥4 events in the first 10 patients, ≥7 events in the first 20 patients, or ≥9 events in the first 30 patients are seen, the study will be halted. We hypothesize that the grade 3 fibrosis rate in our study will be ≤5%. Assuming an actual rate of 4%, an unacceptable rate of 9%, and a drop-out rate of 10%, the expected sample size is 176.

Sites: Ohio State University, Avera Medical Group, University of North Carolina-Chapel Hill

Patient Accrual: Current accrual is 5/176.

Contact Information: Jose Bazan (jose.bazan2@osumc.edu)

Funding Source: Intraop Medical

Citation Format: Bazan JG, Stephens J, Agnese D, Skoracki R, Arneson K, Reiland J, Gupta G, Gallagher K, McElroy S, Gupta N, White JR. Multi-institution phase II trial of intraoperative electron beam radiotherapy boost at the time of breast conserving surgery with oncoplastic reconstruction in women with early-stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-04.

Abstract P5-11-09: Feasibility of tracking plasma DNA mutation kinetics in estrogen receptor positive metastatic breast cancer using a novel digital PCR amplicon sequencing assay

Estrogen Receptor 1 (ESR1) gene mutations in estrogen receptor positive (ER+) metastatic breast cancer (MBC) are associated with clinical resistance to endocrine therapy. A highly sensitive digital PCR (dPCR) assay was developed to evaluate the baseline abundance and kinetics of hotspot ESR1 mutations in plasma circulating tumor DNA (ctDNA) from 58 ER+ MBC patients who had progressed on at least one line of prior endocrine therapy. Consistent with prior reports, we demonstrate that detection of hotspot ESR1 mutations in plasma ctDNA is associated with shorter progression-free survival. However, after patients initiated a new course of systemic therapy, changes in plasma ESR1 mutation abundance did not correlate with the duration of disease control. To investigate whether mutational heterogeneity may account for this lack of correlation, we developed a customized dPCR multiplexed amplicon next-generation sequencing (NGS) assay to detect plasma ctDNA mutations in the complete coding sequence of ESR1 and TP53, as well as hotspot regions in PIK3CA. Assay validation revealed a 79% sensitivity and 100% specificity for detecting plasma ctDNA mutations with a lower limit of detecting a 1.6% mutant allele fraction. The NGS assay revealed non-hotspot ESR1 mutations in plasma DNA from 14 of 31 (45%) patients. We also observed dynamic changes in plasma ctDNA mutant allele fraction of PIK3CA and TP53 during systemic therapy. Changes in the cumulative mutant allele fraction of ESR1, PIK3CA, and TP53 in plasma ctDNA correlated with duration of clinical treatment response in a limited subset of patients (n=8) for whom NGS was performed at two or more time points. Thus, mutational heterogeneity limits the clinical utility of monitoring individual hotspot mutations in ESR1 over time in ER+ MBC patients. However, a plasma ctDNA NGS assay targeting ESR1, PIK3CA, and TP53 may be useful as an early predictor of response to systemic therapy.

Citation Format: Kumar S, Lindsay D, Chen B, Garrett AL, Tan XM, Anders CK, Carey LA, Gupta GP. Feasibility of tracking plasma DNA mutation kinetics in estrogen receptor positive metastatic breast cancer using a novel digital PCR amplicon sequencing assay [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 P5-11-09.

Abstract P1-06-05: Mre11 mediates a p53-independent quiescence program in response to mammary oncogene activation

Background: Oncogenic mutations drive uncontrolled proliferation, imposing significant replication stress and activating the DNA damage response (DDR) in early tumorigenesis. The accumulation of double strand breaks (DSBs) is recognized by the Mre11-Nbs-Rad50 (MRN) Complex, a critical sensor that mediates damage signaling and cell cycle checkpoint responses. The mechanism by which the DDR acts as an anti-tumor barrier is in part due to activation of p53 tumor suppressor. However, the role of the DDR in a p53 null or deficient setting has been poorly investigated. In basal-like breast cancer (BLBC) where p53 loss is ubiquitous, the functional consequence of the DDR is in need of further delineation. Previously, we have observed that Mre11 suppresses proliferation in hyperplastic mammary epithelium through a p53-independent mechanism. Here, we evaluate how Mre11 affects cell cycle regulation in p53 deficient primary mammary epithelium induced to overexpress the oncogene c-Myc, a known driver of BLBC.

Methods: We performed single-cell live imaging on primary murine mammary epithelial cells (mMECs) induced to overexpress c-Myc and be p53 deficient, with or without additional mutations in Mre11. Cells were further infected with a fluorescent cell cycle reporter: Proliferating Cell Nuclear Antigen (PCNA)-mCherry. By tracking PCNA foci changes via time-lapse imaging modalities, we were able to calculate distinct cell cycle phase lengths, identify disruption of cell cycle, visualize mitotic aberrancies, and characterize the cell cycle profile of p53 deficient, c-Myc activated primary mammary epithelial cells with or without intact DDR.

Results: Our results indicate that the presence of Mre11 mediates a quiescence phenotype even in the absence of p53 tumor suppressor with up to 75% of the cell fraction becoming quiescent. This fraction is significantly reduced (p&lt;0.0001) when Mre11 is targeted using gene editing giving rise to highly aberrant multinucleated mMECs capable of unrestrained replication and entry into mitosis. Cells with intact Mre11 undergo cell cycle arrest post abnormal mitoses and are characterized by quiescent cells with classic micronuclei formation. In contrast, mMECs without Mre11 are likely to be multinucleated with reduced micronuclei formation and rarely undergo cell cycle arrest. The loss of Mre11 enables these cells to continue cell cycle progression despite tremendous mitotic aberrancies. Impact: Mre11 is an important mediator of a p53 independent quiescence program in c-Myc expressing cells. It regulates the proliferative activity of multinucleated daughter cells and their ability to become quiescent. Furthering our understanding of how Mre11 regulates this molecular quiescence program may provide new insights into drivers of genomic instability in BLBC and novel therapeutic targets.

Citation Format: Kumar RJ, Xiao HC, Fagan-Solis K, Purvis J, Gupta GP. Mre11 mediates a p53-independent quiescence program in response to mammary oncogene activation [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-06-05.

Abstract P1-06-08: A p53-independent DNA damage response that regulates breast cancer phenotypes

Defects in the DNA damage repair system result in increased genomic instability and have recently been implicated as being drivers of tumorigenesis in both familial and sporadic breast cancers. To maintain genomic integrity, cells have a DNA damage response (DDR) mechanism that functions to repair damaged DNA efficiently and commits cells to death if damage is irreparable. Failure of this mechanism results in genomic instability and cancer predisposition. Widespread chromosomal instability is a characteristic feature of Triple-Negative Breast Cancer (TNBC), making it difficult to decipher between genes that drive cancer development from those that play a bystander role. Little is known about what gives rise to the extensive genomic instability of TNBC, and presents a major deficit in our scientific and clinical knowledge.

Oncogene induced hyper-proliferation results in replication-associated double strand breaks (DSBs) that engage an Mre11-Rad50-Nbs1 complex-dependent DDR. Classically, the oncogene induced DDR is believed to suppress tumorigenesis due to downstream activation of p53. Using genetically engineered primary mammary epithelial cell models, we demonstrate p53-independent effects of the Mre11-dependent DDR in suppressing proliferation and DNA damage induced by diverse oncogenic drivers. Single cell whole genome sequencing in Her2/Neu expressing primary mammary epithelial cells reveals a landscape of stochastic copy number aberrations induced by oncogenic stress that becomes enriched for a genomic scar pattern of larger-size deletions in cells with Mre11 hypomorphism. We identify Mre11 pathway hypomorphism in a subset of basal-like breast cancers (BLBC), which confers vulnerability to specific DNA damaging agents and DDR inhibitors in murine models of p53-deficient BLBC. Thus, assessing the functional status of the Mre11-dependent DDR pathway in p53-mutant breast cancers may provide an opportunity for therapeutic exploitation.

Citation Format: Fagan-Solis KD, Simpson DA, Kapustina M, Martelotto L, Reis-Filho JS, Petrini JH, Gupta GP. A p53-independent DNA damage response that regulates breast cancer phenotypes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-06-08.

How are gender inequalities facing India's one million ASHAs being addressed? Policy origins and adaptations for the world's largest all-female community health worker programme

BACKGROUND

India's accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations.

METHODS

We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper's government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens.

RESULTS

Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation.

CONCLUSIONS

Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs' access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.

Primary uterine angiosarcoma with "rhabdoid morphology": A case report

INTRODUCTION

Primary uterine angiosarcoma is a very rare tumour, with only 23 cases described till now. It is a malignant tumour with cells variably recapitulating the morphologic features of an endothelium and expressing immunohistochemical markers of endothelial cells. In general, it is a bulky neoplasm and frequently is at advance stage of disease at presentation. In general, patients with uterine angiosarcoma tend to have a poorer prognosis, mostly related to the aggressive nature and the metastatic potential of these tumours.

CASE REPORT

We report a rare case of primary uterine angiosarcoma with unusual rhabdoid morphology in a 41-year-old female, who underwent radical hysterectomy and died of disease after 4 months of treatment.

DISCUSSION

We described the differential diagnosis of primary angiosarcoma of the uterus that can pose a diagnostic challenge.

Abstract P4-10-04: EMBRACE (Ending metastatic breast cancer for everyone): A comprehensive approach to improve the care of patients with metastatic breast cancer

Background: In contrast to early stage breast cancer, the quality of care for patients with metastatic breast cancer (MBC) has been relatively understudied, as have interventions to improve care in the real-world setting. Patients with MBC face a variety of unique needs related to their disease, treatment options, and supportive care. Little attention has been focused on leveraging the strengths of academic and community-based settings to provide optimal care for these patients. To address these critical issues, we have designed and implemented a comprehensive program that combines clinical care, clinical research, physician engagement and patient education to optimize the care of MBC patients.

Methods: We developed a consistent and comprehensive intake process and follow-up approach for MBC patients who were seen at least once in the Breast Oncology Clinic (BOC) at Dana-Farber Cancer Institute (DFCI). A key component of our approach is the EMBRACE coordinator who meets with each MBC patient at the first clinic visit to review the clinical program, available educational and supportive resources, and consents to research studies. Each coordinator supports the DFCI-based oncologist and follows a discrete patient panel longitudinally, for whom they are responsible for facilitating referrals to supportive care resources, identifying potential candidates for trial prescreening, tracking availability of results from molecular testing for clinical trial matching, facilitating communication between DFCI-based providers and referring providers and organizing re-consultation visits when clinically appropriate. The coordinator contacts patients every 3 months to inquire about the patient's overall health and needs and provides updates on upcoming educational and supportive care activities at our institution. Educational offerings have been expanded to include a bi-annual newsletter, quarterly email updates, webcasts and an annual educational patient forum. Results: The program was fully implemented in the BOC across 27 oncologists in August 2016, after the start of a pilot in July 2015. On average, the program enrolls 30 to 40 new MBC patients per month at their initial visit. The EMBRACE coordinators currently support the DFCI-based oncologists in the care of approximately 1500 new and existing MBC patients and facilitate collaborations with 350 referring providers.

Conclusions: The EMBRACE program has made a tangible improvement in the quality of care for patients with MBC in our clinic. We have successfully established the infrastructure of the coordinator role and a robust tracking system to support the patient, DFCI-based provider, and referring provider. While the program has been solely based at DFCI, we believe that our approach has the potential for impact beyond our institution and ultimately serve as a model for enhanced academic-community-patient partnership.

Citation Format: Hughes ME, Frank ES, Merrill MS, Santiago RA, Kuhnly N, Crowley LM, Gupta G, Winer EP, Lin NU. EMBRACE (Ending metastatic breast cancer for everyone): A comprehensive approach to improve the care of patients with metastatic breast cancer [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 P4-10-04.

Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor

A 42-year-old hypothyroid shepherd presented with a progressive abdominal lump accompanied by nausea and abdominal fullness. In addition, he had worsening hypothyroidism, despite supranormal doses of thyroxine. Computed tomography of the abdomen was suggestive of a mass lesion in relation to the stomach. A resection of the mass was done and the histopathology was suggestive of gastrointestinal stromal tumor. After surgery, the patient became euthyroid. We believe the patient had consumptive hypothyroidism due to the tumor.

Real Time Central Assessment of Kidney Transplant Indication Biopsies by Microarrays: The INTERCOMEX Study

The authors conducted a prospective trial to assess the feasibility of real time central molecular assessment of kidney transplant biopsy samples from 10 North American or European centers. Biopsy samples taken 1 day to 34 years posttransplantation were stabilized in RNAlater, sent via courier overnight at ambient temperature to the central laboratory, and processed (29 h workflow) using microarrays to assess T cell- and antibody-mediated rejection (TCMR and ABMR, respectively). Of 538 biopsy samples submitted, 519 (96%) were sufficient for microarray analysis (average length, 3 mm). Automated reports were generated without knowledge of histology and HLA antibody, with diagnoses assigned based on Molecular Microscope Diagnostic System (MMDx) classifier algorithms and signed out by one observer. Agreement between MMDx and histology (balanced accuracy) was 77% for TCMR, 77% for ABMR, and 76% for no rejection. A classification tree derived to provide automated sign-outs predicted the observer sign-outs with >90% accuracy. In 451 biopsy samples where feedback was obtained, clinicians indicated that MMDx more frequently agreed with clinical judgment (87%) than did histology (80%) (p = 0.0042). In 81% of feedback forms, clinicians reported that MMDx increased confidence in management compared with conventional assessment alone. The authors conclude that real time central molecular assessment is feasible and offers a useful new dimension in biopsy interpretation. ClinicalTrials.gov NCT#01299168.