Abstract P4-03-07: Analysis of hereditary cancer syndromes by using a panel of genes: Novel and multiple pathogenic mutations

BACKGOUND: Hereditary cancer predisposition syndromes are believed to be responsible for approximately 5-10% of all diagnosed cancer cases. In the past, single genes analysis of certain high risk genes was used for the determination of the genetic cause of cancer heritability in certain families. The selection of genes was mainly based on the family history of the individuals analyzed and included only highly associated genes (e.g. the BRCA1 and BRCA2 genes for families with breast cancer history. Nowadays though, the application of Next Generation Sequencing (NGS) technology has facilitated multigene panel analysis and is widely used in clinical practice, for the identification of individuals with cancer predisposition gene mutations.

AIM: The aim of this study was to investigate the extent and nature of mutations in 36 genes implicated in hereditary cancer predisposition in individuals referred for testing in our lab.

MATERIALS & METHODS: In total, 1197 individuals were referred for testing in our lab in the past four years from Greece, Romania and Turkey. The analysis of genes involved in hereditary cancer predisposition was performed using two NGS approaches. The first 451 individuals were analyzed using an amplicon based sequencing method (26 gene panel), while the following 746 individuals were analyzed using a capture based method (33 gene panel). Genomic DNA was enriched for targeted regions of 36 genes involved in hereditary predisposition to cancer included in both versions of the panel (APC, BMPR1A, BRCA1, BRCA2, CDH1, CDK4, CDKN2A, EPCAM, MEN1, MLH1, MSH2, MSH6, MUTYH, PALB2, PMS2, PTEN, RET, SMAD4, STK11, TP53, VHL, ATM, BRIP1, CHEK2, NBN, RAD51C, RAD51D, BARD1, BLM, CHEK1, ABRAXAS1 (FAM175A), MRE11 (MRE11A), NF1, RAD50, RAD51B, XRCC2). Sequencing was carried out using the Illumina NGS technology. Reads were aligned to the reference sequence (GRCh37), and sequence changes were identified and interpreted in the context of a single clinically relevant transcript. The presence of large genomic rearrangements was investigated by computational analysis of NGS results and the use of MLPA for 13 genes. All clinically significant observations were confirmed by orthogonal technologies.

RESULTS: In total, a pathogenic mutation was identified in 259 of the 1197 individuals (21.6%) analyzed while a VUS was identified in 35.7% of the cases. Clinically significant mutations were identified in 29 of the genes analyzed. Concerning the mutation distribution among individuals with positive findings, 44.7% of them were located in BRCA1/2 genes whereas 20.9%, 19.9%, and 14.5% in high, moderate and low risk genes respectively. In addition to BRCA1 and BRCA2 genes other highly mutated genes were CHEK2 (10.6%), PALB2 (7.1%), MUTYH (7.1%) and ATM (4.3%). Of note is that 25 of the 259 positive individuals (9.7%) carried clinically significant mutations in two different genes and 5.8% had a large genomic rearrangement (LGR).

CONCLUSIONS: Our results support the clinical significance of analysis of a panel of genes involved in hereditary cancer predisposition. In our cohort, analysis of this panel allowed for the identification of 8.3% additional pathogenic variants in moderate/low risk genes, enabling personalized management of these individuals.

Citation Format: Tsoulos N, Tsaousis GN, Papadopoulou E, Agiannitopoulos K, Pepe G, Kambouri S, Apessos A, Diamantopoulos N, Floros T, Iosifidou R, Katopodi O, Koumarianou A, Markopoulos C, Papazisis K, Venizelos V, Xanthakis I, Xepapadakis G, Banu E, Eniu DT, Negru S, Stanculeanu DL, Ungureanu A, Ozmen V, Tansan S, Tekinel M, Yalcin S, Nasioulas G. Analysis of hereditary cancer syndromes by using a panel of genes: Novel and multiple pathogenic mutations [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 P4-03-07.

Access to Genetic Testing Impacts Oncologists´ Decisions on Ovarian Cancer Personalized Treatment: Lessons Learned From a National Program in Greece

Background: State health insurance authorities in Greece do not reimburse genetic testing for cancer predisposition. The Hellenic Society of Medical Oncology has launched and carries out a national program covering genetic testing for BRCA1/2 mutations detection, with the financial support of pharmaceutical industry. Aim: This analysis evaluates how, during this program, access to genetic testing transformed the oncologists' therapeutic approach toward their ovarian cancer patients and how the results impacted treatment decisions concerning PARP inhibitors. Adoption of testing by healthy relatives and timing of testing in the disease continuum were also evaluated. Methods: Adult patients with high-grade epithelial ovarian carcinoma, irrespectively of family history or age at diagnosis were eligible for this program. Genetic counseling was recommended before testing, and both were offered at no financial cost. First degree family members of pathogenic mutation carriers were also offered free counseling and testing. Results: From March 2015 through January 2018, 708 patients were enrolled and tested. One hundred and forty seven (20.7%) mutation carriers were identified, 102 (14.4%) in BRCA1 and 45 (6.3%) in BRCA2 gene. Testing was more often pursued at initial diagnosis (61%) than at recurrence (39%), as recorded for 409 patients with available relevant information. During the 1st year of the program, average monthly tests performed were 25.1, while during the 3rd year this number increased to 34.3 tests per month. Among patients who tested positive for deleterious BRCA1/2 mutations, relapse was reported in 58 patients, 94.8% of which (n= 55) received treatment with the PARP inhibitor olaparib as per its indication. Family members of 21 patients (14.3%), out of the 147 who tested positive, received genetic counseling and testing for the mutation identified in the context of the program. Conclusion: Free access to genetic testing for BRCA1/2 for ovarian cancer patients and genetic consultation facilitates testing uptake, affects common clinical practice & has major impact on patients and their families. Still, diffusion of genetic information and broader testing of family members require further efforts by the oncological community.

Abstract P2-07-02: Tumor infiltrating lymphocytes density and coding mutations effects on the outcome of operable triple negative breast cancer patients

Background-Aim: Neoantigens are considered to trigger host immune responses against tumors, which may be reflected by tumor infiltrating lymphocytes (TILs) density within the tumor stroma. High TILs levels have been associated with favorable triple-negative breast cancer (TNBC) patient outcome. Herein we evaluated the presence of coding mutations and TILs density with regard to outcome in a cohort of TNBC patients treated with anthracycline-based adjuvant chemotherapy.

Patients and Methods: Paraffin TNBC tissues from 242 patients treated in the context of four prospective clinical trials were histologically reviewed and submitted to massively parallel semiconductor sequencing with a custom panel targeting 57 breast cancer (BC)-related genes. Mutations (mut) were evaluated in 210 informative samples as missense/nonsense amino acid changing variants, with minor allele frequency <1% in the case of single nucleotide polymorphisms. TILs density was morphologically evaluated as percent of the stromal area in 197 tumors; lymphocyte predominant (LP) BC tumors were called for TILs >50%. Disease-free survival (DFS) was used as the endpoint for the present analysis.

Results: 426 Mut were observed for 40 genes in 147 TNBC patients (70%). Among mutated genes, ranging from 1 in 97 tumors up to >10 in 8 tumors, the most frequently affected were TP53 (102 tumors, 69%) and PIK3CA (40 tumors, 27%). Intriguingly, mut rate (p=0.042) and number of mut genes (p=0.018) per tumor were inversely associated with TILs density. Nineteen tumors (10%) were LP-TNBC, carrying TP53 and PIK3CA mut as the only coding alterations in 10 and 3 cases, respectively. LP-TNBC patients did not experience any relapses during a follow-up period of 46-152 months (mean 66 months). For the 90% of non-LP-TNBC, the previously reported outcome benefit for 10% increments of TILs density was only demonstrated for tumors with 31-50% TILs. In non-LP-TNBC, upon adjustment for standard clinicopathological parameters, PIK3CA mut, TP53 mut and TILs density as a continuous variable, TP53 mut and nodal status independently conferred unfavorable DFS (HR=1.89, 95% CI 1.03-3.47, p=0.040 and HR=2.89, 95% CI 1.59-5.24, p=0.001, respectively). When continuous TILs density was added in the multivariate models in the entire cohort, 10% increments significantly predicted favorable DFS (HR=0.73, 95% CI 0.59-0.91, p=0.006), while high nodal status predicted unfavorable DFS (HR=2.75, 95% CI 1.51-4.99, p<0.0001).

Conclusions: In the present study, tumors with higher TILs density, including LP-TNBC, were not characterized by multiple mutations or mutated genes with the panel tested. In TNBC, increasing TILs density is a strong favorable and high nodal status a strong unfavorable prognosticator. Importantly, LP-TNBC may be regarded as a distinct subgroup with excellent prognosis concerning 10% of TNBC. In non-LP-TNBC, TP53 mut and nodal status were significant unfavorable prognosticators. These data may suggest that the level of morphologically assessed TILs density does not necessarily correspond to the tumoral mutational load and merit validation in larger cohorts.

Citation Format: Kotoula V, Fountzilas E, Chatzopoulos K, Alexopoulou Z, Timotheadou E, Xanthakis I, Gogas H, Skondra M, Christodoulou C, Papadopoulou K, Chrisafi S, Koutras A, Xepapadakis G, Venizelos V, Efstratiou I, Patsea H, Kalogeras KT, Lakis S, Fountzilas G. Tumor infiltrating lymphocytes density and coding mutations effects on the outcome of operable triple negative breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-07-02.

Abstract P4-14-05: Genomic parameters affecting the outcome of patients with advanced breast cancer treated with trastuzumab

Background-Aim: There is an unmet need for de-selecting HER2-positive patients with advanced breast cancer (ABC), since only some of those patients benefit from the addition of anti-HER2 agents to chemotherapy. The aim of this study was to investigate candidate biomarkers, including MYC and MET, in parallel with an extended array of biomarkers previously associated with trastuzumab (T) resistance.

Patients and Methods: Two hundred and twenty-nine ABC patients treated with T and chemotherapy over a period of 13 years were included in the study. Paraffin tumors were retrospectively centrally assessed with immunohistochemistry (IHC) for breast cancer subtypes; fluorescence in situ hybridization (FISH) for HER2, TOP2A and centromere (CEN) 17, MYC and CEN8, MET and CEN7; qPCR for MYC and MET copy number (CN); and, for PI3K activation (PIK3CA mutations, PTEN and phospho-mTOR IHC). Patterns of CEN CN aberrations corresponding to chromosome "polysomy" were also evaluated, with cut-offs based on normal tissue. Time to progression (TTP) and survival were evaluated from the initiation of T as first-line treatment.

Results: Median follow-up was 70 months. Of the 229 patients treated with T as HER2-positive, central analysis identified 90 cases being HER2-negative, as per current guidelines (39.3% of the total cohort). HER2-positive patients showed a trend for survival benefit over HER2-negative patients (median 50.7 vs. 38.1 months, respectively, p=0.118). HER2-positive tumors were subtyped as Luminal-HER2 (n=77) and HER2-enriched (n=53); 156 patients presented with ABC and 65 with disease initially diagnosed at stage IV (de novo ABC). MET and MYC CN gains (≥2.5 copies) were found in 40 (25%) and 15 (9%) cases with qPCR, while MET and MYC amplification with FISH was present in 4 (2.5%) and 31 (18%) cases, respectively. Concordance between FISH and qPCR was low for MYC (kappa value 0.46) and absent for MET. Polysomy was collectively observed in 70 cases, in 54 of them (32% of all tumors) concerning any 1 of the 3 examined chromosomes. This condition, called restricted polysomy, interacted with ABC presentation, conferring decreased survival to patients with ABC (HR=2.32, 95% CI 1.43-3.76, Wald's p=0.001) but not to those with de novo ABC (interaction p=0.077). MYC CN gain was the only marker significantly associated with increased risk for progression (HR=3.22, 95% CI 1.66-6.24, p<0.001) and death (HR=5.45, 95% CI 2.89-10.28, p<0.001) at univariate analysis. Adjustment of all tested markers with standard clinicopathological parameters revealed that along with poor patient performance status that was associated with poor prognosis, MYC CN gain was an independent adverse prognosticator for both TTP and survival (all p-values <0.001). The HER2-enriched subtype was independently associated with T benefit for TTP (p=0.001) and survival (p=0.051). The interaction between restricted polysomy and disease presentation was also independently significant for survival (p=0.041).

Conclusions: MYC CN gain is a strong unfavorable prognosticator in T-treated ABC patients. Distinguishing between HER2-positive subtypes seems important for identifing T benefit in ABC. Chromosomal polysomy may distinctly affect T benefit in patients with pre-treated and de novo ABC.

Citation Format: Gogas H, Kotoula V, Alexopoulou Z, Christodoulou C, Kostopoulos I, Bobos M, Raptou G, Charalambous E, Tsolaki E, Xanthakis I, Pentheroudakis G, Koutras A, Bafaloukos D, Papakostas P, Aravantinos G, Psyrri A, Petraki K, Kalogeras KT, Fountzilas G, Pectasides D. Genomic parameters affecting the outcome of patients with advanced breast cancer treated with trastuzumab. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-05.

Prospective, open-label, randomized, phase III study of two dose-dense regimens MVAC versus gemcitabine/cisplatin in patients with inoperable, metastatic or relapsed urothelial cancer: a Hellenic Cooperative Oncology Group study (HE 16/03)

BACKGROUND

The combinations of methotrexate, vinblastine, Adriamycin, cisplatin (Pharmanell, Athens, Greece) (MVAC) or gemcitabine, cisplatin (GC) represent the standard treatment of advanced urothelial cancer (UC). Dose-dense (DD)-MVAC has achieved longer progression-free survival (PFS) than the conventional MVAC. However, the role of GC intensification has not been studied. We conducted a randomized, phase III study comparing a DD-GC regimen with DD-MVAC in advanced UC.

PATIENTS AND METHODS

One hundred and thirty patients were randomly assigned between DD-MVAC: 66 (M 30 mg/m(2), V 3 mg/m(2), A 30 mg/m(2), C 70 mg/m(2) q 2 weeks) and DD-GC 64 (G 2500 mg/m(2), C 70 mg/m(2) q 2 weeks). The median follow-up was 52.1 months (89 events).

RESULTS

The median overall survival (OS) and PFS were 19 and 8.5 months for DD-MVAC and 18 and 7.8 months for DD-GC (P = 0.98 and 0.36, respectively). Neutropenic infections were less frequent for DD-GC than for DD-MVAC (0% versus 8%). More patients on DD-GC received at least six cycles of treatment (85% versus 63%, P = 0.011) and the discontinuation rate was lower for DD-GC (3% versus 13%).

CONCLUSIONS

Although DD-GC was not superior to DD-MVAC, it was better tolerated. DD-GC could be considered as a reasonable therapeutic option for further study in this patient population. Clinical Trial Number ACTRN12610000845033, www.anzctr.org.au.

Clear cell ovarian carcinoma following polymyositis diagnosis: a case report and review of the literature

BACKGROUND

The association of ovarian malignancy with dermatomyositis (DM) is well established from previous reports, while the relationship with polymyositis (PM) is rare.

CASE REPORT

We report a case of a 50 years old nulliparous woman who developed clear cell ovarian cancer four years after the PM diagnosis. The patient presented with deep lower abdominal pain and distension. CA-125 was elevated and the preoperative MRI showed pelvic tumor occupying the Douglas pouch. Exploratory laparotomy revealed a gross mass of clear cell ovarian carcinoma.

CONCLUSION

Physicians must be alert of the possibility of malignancy in patients with a previous diagnosis of polymyositis.

Relative bioavailability study of two nifedipine tablet formulations in healthy male volunteers

OBJECTIVE

To assess the bioequivalence of two oral formulations containing 10 mg of nifedipine. The test preparation were Macorel tablets, the reference preparation were Adalat tablets.

SUBJECTS, MATERIAL AND METHODS

The study was designed as a single-dose, three-period crossover randomized design to 18 non-smoker, healthy male volunteers under fasting conditions. Seventeen volunteers completed the study. Plasma samples were analyzed for nifedipine by HPLC after solid-phase extraction. The pharmacokinetic parameters used to assess the bioequivalence of the two formulations were AUC(0-infinite) and AUC(0-t) for the extent of absorption and Cmax and Tmax for the rate of absorption. Statistical comparisons of AUC(0-infinite) AUC(0-t), and Cmax data were evaluated after logarithmic transformation by two-way analysis of variance (ANOVA), and differences of Tmax were tested non-parametricaly.

RESULTS

Point estimates (90% confidence intervals) of the test/reference ratios were 97.4% (87.6%-108.3%) for AUC(0-infinite) 97.0% (85.6%-110.1%) for AUC0-t, and 107.7% (89.1%-130.7%) for Cmax. No statistically significant difference was found for Tmax and elimination half-life values.

CONCLUSION

Therefore, in accordance with the European Union bioequivalence requirements, the test and reference nifedipine preparations are bioequivalent for both the extent and the rate of absorption.

Bioequivalence of two tablet formulations of atenolol after single oral administration in healthy volunteers

The pharmacokinetic parameters of two oral formulations of 100 mg tablets of atenolol (CAS 29122-68-7; Azectol as test and another commercially available preparation as reference) were compared in an open-label, randomized, single oral dose, two-period cross-over design to 17 healthy volunteers under fasting conditions. Serial blood samples were collected prior to each administration and at 17 points within 36 h after dosing. Plasma concentrations of atenolol were measured by a validated HPLC assay with fluorometric detection. The parametric 90% confidence intervals of the geometric mean values of the test/reference ratios were 94.4% to 112.9% (point estimate: 103%) for AUC0-infinity, 93.7% to 112.8% (point estimate: 103%) for AUC0-36, and 88.3% to 112.1% (point estimate: 100%) for Cmax, within the acceptance criteria for bioequivalence (80%-125%). Tmax values were analyzed by the nonparametric Wilcoxon test and the difference was not statistically significant. Therefore, it is concluded that the test and reference atenolol formulations are bioequivalent for both the extent and the rate of absorption.

Prevalence of cryoglobulinemia in chronic hepatitis C virus infection and response to treatment with interferon-alpha

Chronic hepatitis C virus (HCV) infection is associated with a variety of clinically important extrahepatic abnormalities. We have assessed the prevalence of cryoglobulinemia and of the clinical syndrome associated with it in patients with chronic HCV infection. We also have evaluated the clinical, serologic, and biochemical response to antiviral treatment with interferon-alpha (IFN-alpha). Eighty-one patients with chronic liver disease associated with HCV infection were included. Cryoglobulins were sought in the serum. All patients were examined carefully for clinical manifestations of cryoglobulinemia (e.g., palpable purpura, Raynaud's syndrome, arthritis, peripheral neuropathy, Sjögren's syndrome, glomerulonephritis). Antiviral treatment with IFN-alpha, at a dose of 3 to 5 million units, 3 times weekly, was given to 20 patients with cryoglobulinemia. Cryoglobulins were detected in 45.7% of patients. Signs and symptoms of the clinical syndrome associated with cryoglobulinemia were present in 12.3% of the entire group of patients (27% of the subgroup with detectable cryoglobulins). Patients with cryoglobulinemia were older (mean age, 56 +/- 15 vs. 44 +/- 16 years; p = 0.002) and had a higher rate of cirrhosis (48.6% vs. 18.2%, rate ratio = 4.26, 95% confidence interval = 2.11 to 8.58, p = 0.00005) compared to patients without cryoglobulinemia. Cryoglobulins disappeared from the serum in 13 (65%) of the 20 patients who were treated for 6 to 12 months with IFN-alpha. This effect was affiliated in most patients with resolution of the clinical findings associated with cryoglobulinemia and return of transaminases to normal levels. Recurrence of cryoglobulinemia was observed in two thirds of the patients who were observed after treatment with IFN-alpha. We conclude that cryoglobulins are present in 45.7% of patients with chronic HCV infection. Symptoms or signs or both associated with the presence of cryoglobulins develop in a high proportion (27%) of these patients. Antiviral treatment with IFN-alpha leads to resolution of both cryoglobulinemia and the symptoms associated with it in most patients who also show a biochemical response to antiviral treatment. Recurrence is frequent after treatment withdrawal.