Mimicking the breast metastatic microenvironment: characterization of a novel syngeneic model of HER2+ breast cancer

Preclinical murine models in which primary tumors spontaneously metastasize to distant organs are valuable tools to study metastatic progression and novel cancer treatment combinations. Here, we characterize a novel syngeneic murine breast tumor cell line, NT2.5-lung metastasis (-LM), that provides a model of spontaneously metastatic neu-expressing breast cancer with quicker onset of widespread metastases after orthotopic mammary implantation in immune-competent NeuN mice. Within one week of orthotopic implantation of NT2.5-LM in NeuN mice, distant metastases can be observed in the lungs. Within four weeks, metastases are also observed in the bones, spleen, colon, and liver. Metastases are rapidly growing, proliferative, and responsive to HER2-directed therapy. We demonstrate altered expression of markers of epithelial-to-mesenchymal transition (EMT) and enrichment in EMT-regulating pathways, suggestive of their enhanced metastatic potential. The new NT2.5-LM model provides more rapid and spontaneous development of widespread metastases. Besides investigating mechanisms of metastatic progression, this new model may be used for the rationalized development of novel therapeutic interventions and assessment of therapeutic responses targeting distant visceral metastases.

Prevalence and risk factors for common respiratory pathogens within a cohort of pet cats in the UK

OBJECTIVES

Feline herpesvirus (FHV), feline calicivirus (FCV) and Chlamydia felis are common causes of upper respiratory tract disease (URTD) in cats. Their prevalence in the UK pet cat population has not been reported and little is known regarding the risk factors for their oral carriage.

METHODS

Total nucleic acid was extracted from owner-collected buccal swabs (n=600) from cats enrolled in a self-selected longitudinal cohort study. Duplex quantitative PCRs for the detection of FHV and C. felis genomic DNA and reverse-transcriptase quantitative PCRs for the detection of FCV genomic RNA were performed. Duplicates, swabs with insufficient host DNA/RNA, and cats with missing data were excluded. Selected epidemiological data were interrogated using univariable and multi-variable logistic regression modelling to identify risk factors.

RESULTS

Data from 430 cats were included in the final statistical model. Of these, 2.1% (n=9/430; 95% CI 1.0% to 3.9%) were positive for FHV, 13.3% (n=57/430; 95% CI 10.2% to 16.8%) positive for FCV and 1.2% (n=5/430; 95% CI 0.4% to 2.7%) positive for C. felis. FCV co-infection was present in five (44%) FHV-positive cats and three (60%) C. felis-positive cats. FCV carriage was more frequent in purebred cats (odds ratio 2.48; 95% CI 1.37 to 4.49) and in cats with current or historical clinical signs compatible with URTD (odds ratio 2.98; 95% CI 1.22 to 7.27).

CLINICAL SIGNIFICANCE

FCV was the most frequently encountered URTD pathogen in this sample of cats; this should be noted for disinfectant choice. In cats suspected of having FHV or C. felis infection, assessment for co-infection with FCV is recommended.

Abstract P2-06-04: Effects of BMI velocity on outcomes in patients with metastatic breast cancer in the Dallas Metastatic Breast Cancer Study

BACKGROUND: The Dallas Metastatic Breast Cancer Study (DMBCS) is a clinical database that was established in 2021 at a single academic medical system to track patient demographics, associated pathology, treatments, and other variables that are not widely available in the Surveillance, Epidemiology, and End Results (SEER) Program for metastatic breast cancer (MBC). One of many ongoing studies as part of the DMBCS is to investigate how weight loss after diagnosis affects outcomes in MBC patients. Although previous studies have shown that significant weight loss is associated with poorer outcomes in certain cancer types, little is known about its role in breast cancer. METHODS: 139 patients who were diagnosed with MBC between 2009-2021 were included in this data collection. BMI at the time of diagnosis of MBC and within 6 months of death or last follow-up were recorded. BMI velocity was calculated by dividing the difference between BMI at diagnosis and BMI at time of death (or last follow-up) by the number of months between initial diagnosis and time of death (or last follow-up). The BMI velocity represents the rate at which patients lost or gained weight during their disease course. A negative BMI velocity indicates weight loss, and a positive BMI velocity indicates weight gain over the defined period. The absolute value of the BMI velocity indicates how rapidly someone gains or loses weight. The association of BMI velocity on the primary outcome (overall survival (OS) and progression-free survival (PFS)) was assessed using Cox proportional hazard (PH) model. Adjusted hazard ratios (HR) with 95% confidence intervals were computed using the multivariable Cox PH model. RESULTS: At the time of diagnosis of MBC, 40% were obese and 33% were overweight. At the time of death or last follow-up, 27% were obese and 31% were overweight. The mean BMI velocity was -0.13 per month. Contrary to previous studies that have shown a negative effect of obesity on OS, we found that obesity at the time of diagnosis of MBC did not statistically worsen OS and PFS. However, compared to patients who had negative BMI velocities, improved OS (lower hazard ratio) was noted for patients with stable or increasing BMI velocities (HR = 0.53; 95% CI = 0.32-0.88, p = 0.014). A greater rate of weight loss was also associated with worse OS (HR = 0.23; 95% CI = 0.12 - 0.47, p < 0.001) and PFS (HR = 0.29; 95% CI = 0.16 - 0.52, p < 0.001). Improved PFS was seen for patients with stable or increasing BMI velocities in the unadjusted analysis (HR = 0.65; 95% CI = 0.42 - 0.99, p = 0.047). CONCLUSION: Our study found that contrary to previously published results in patients with early-stage breast cancer, obesity did not statistically worsen OS or PFS. However, the rate of weight loss, which we defined as BMI velocity, is associated with higher mortality in MBC. Our findings can be applied to clinical practice when advising MBC patients regarding healthy changes in weight during their disease course. BMI velocity could be used as a prognostic indicator to predict outcomes in patients with MBC. In future studies, we aim to quantify the amount of weight loss that is associated with worse outcomes.

Citation Format: Mir Lim, Mona Pathak, Meng Cao, Anna Moscowitz, Jonathan Ladner, Sangeetha Reddy, Isaac Chan. Effects of BMI velocity on outcomes in patients with metastatic breast cancer in the Dallas Metastatic Breast Cancer Study [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 P2-06-04.

Abstract P4-03-43: Disease characteristics and outcomes of people with metastatic breast cancer in a single center cohort study: The Dallas Metastatic Breast Cancer Study

Background: Breast cancer is the most common cancer in women, and metastatic disease accounts for most breast cancer related deaths. Identifying risk factors for the onset and progression of metastatic breast cancer (MBC) can help us understand how to address and improve morbidity and mortality due to MBC. Large national databases, such the Surveillance, Epidemiology, and End Results (SEER) Program are limited in their ability to capture granular details from patients’ cancer histories. The Dallas Metastatic Breast Cancer Study (DMBCS) is a clinical database established at a single academic medical system to track patient demographics, associated pathology, treatments, and other variables to improve outcomes for patients with MBC. Methods: The DMBCS database was generated from a registry of breast cancer patients submitted to the National Cancer Institute from 2010 to 2021. Patients were initially excluded if they were identified as non-metastatic from this list. Chart review was then done to identify MBC patients from this subsequent group. Demographics, clinical history, pathologic features, lines of treatment, and subsequent recurrences were collected for all patients. Clinical data was stored in REDCap, a secure data collection platform for entering and managing data. Results: 230 cases were included in this preliminary data set. Of the 230 cases, 185 cases were metastatic at time of diagnosis while 45 cases were metastatic recurrences of breast cancer. At diagnosis, 14.8% were less than 40 years of age, 17.3% were 40-49, 35.7% were 50-59, 18.7% were 60-69, and 13.5% were greater than 70 years of age. In terms of ethnicity, 63.5% were White, 27.4% were Black, and 21.7% identified as Hispanic. At time of diagnosis, 30.9% of patients had a BMI classified as overweight and 40.4% were considered obese. Medical comorbidities included hypertension in 43% of cases, diabetes (18.3%), hyperlipidemia (27.4%), and autoimmune disease (13.0%). Clinical subtype analysis revealed 57.8% of patients were hormone receptor positive, 24.8% HER2 positive, and 17.4% triple negative, at diagnosis. 14.8% of cases were diagnosed as inflammatory breast cancer. The most common site of metastasis at presentation was bone with 69.1% of cases, followed by lung (33.9%), liver (30.0%), and brain (15.2%). Over 90% of patients were treated with at least one antineoplastic regimen and 39.6% underwent at least 4 therapies. Calculated 1-year survival after diagnosis was 85.7%. Conclusions: The introduction of the DMBCS will allow continued investigation into clinical drivers of MBC. In this first cohort of patients, we characterized key, yet often underreported, variables and outcomes. Potential applications of this database include investigating the association between obesity and overall survival in patients with MBC, understanding how socioeconomic disparities affects outcomes of patients with MBC, and exploring correlations between autoimmune disease and the progression of MBC.

Citation Format: Meng Cao, Mir Lim, Anna Moscowitz, Jonathan Ladner, Christine Hodgdon, Julia Maues, Sangeetha Reddy, Isaac Chan. Disease characteristics and outcomes of people with metastatic breast cancer in a single center cohort study: The Dallas Metastatic Breast Cancer Study. [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 P4-03-43.

Abstract GS5-06: InteractPrint predicts clinically meaningful interactions between cancer epithelial cells and immune cells: Lessons from a single-cell breast cancer atlas

BACKGROUND: While immunotherapy has revolutionized the treatment of many solid tumors, the efficacy of immunotherapy regimens is comparatively lower in breast cancer. Immunotherapy efficacy is often negatively correlated with intratumor heterogeneity. Novel immunotherapy approaches in breast cancer should leverage how cancer epithelial cell heterogeneity affects immune cells in the tumor microenvironment. However, current definitions of cancer epithelial cell heterogeneity in breast cancer have limited resolution. Single cell RNA-seq (scRNA-seq) provides an unprecedented opportunity to further define cancer epithelial cell heterogeneity and identify how heterogeneity influences interactions with immune cells. METHODS: We generated a novel scRNA-seq dataset of 236,363 cells from 119 primary breast tumors biopsied from 88 patients taken from 8 publicly available datasets, currently the largest published scRNA-seq dataset in breast cancer. To define cancer epithelial cell heterogeneity, we performed unsupervised clustering and supervised clustering based on molecular subtype and expression of clinical target genes on all cancer epithelial cells. This identified 11 gene elements (GEs), which reflect key molecular features that vary between cancer epithelial cells. Receptor-ligand pairing analysis allowed us to determine how cells that highly express each GE interact with various immune cells. We developed InteractPrint, a score to predict the predominant tumor-interacting immune cells, based on the GE composition of an individual patient tumor. RESULTS: In our dataset, 17% of samples were HER2+, 41% were HR+, and 42% were TNBC. This dataset was statistically powered to characterize cancer epithelial cell heterogeneity. For each of the 11 GEs, we predicted interactions with immune cells. Experimentally, GEs with predicted NK cell interactions showed sensitivity to NK cell cytotoxicity. In a spatially resolved transcriptomics dataset, GEs with predicted T cell interactions demonstrated colocalization with CD8+ T cells, while those with limited predicted T cell interactions did not. To infer GE-immune interactions at the patient level (GEs define cell-level interactions), we developed InteractPrint. To validate InteractPrint, we assessed the accuracy of the T cell InteractPrint in predicting response to anti-PD-1 therapy. Across two trials and all breast cancer subtypes, T cell InteractPrint demonstrated significant improvement over PD-L1 in predicting response to anti-PD-1 therapy. In an scRNA-seq dataset of samples from patients treated with pembrolizumab, we observed AUC of 85% (p < 0.005) for T cell InteractPrint vs. 61% (p > 0.05) for PD-L1 in predicting response to anti-PD-1 therapy. In patients treated with paclitaxel + pembrolizumab in the I-SPY 2 trial, we observed AUC of 81% (p < 0.00001) for T cell InteractPrint versus 72% (p = 0.001) for PD-L1. CONCLUSIONS: Our results demonstrate considerable cancer epithelial cell heterogeneity across primary breast tumor samples and clinical subtypes. We defined this heterogeneity and leveraged it to predict immune cell interactions within a patient’s tumor. We developed T cell InteractPrint to capture heterogeneous interactions between cancer epithelial cells and CD8+ T cells. T cell InteractPrint is predictive of response to anti-PD-1 immune checkpoint inhibition at higher AUC than PD-L1. This provides a path forward for the interpretation of cancer epithelial cell heterogeneity in a clinically meaningful way.

Citation Format: Lily Xu, Kaitlyn Saunders, Hildur Knutsdottir, Kenian Chen, Julia Maues, Christine Hodgdon, Evanthia T. Roussos Torres, Sangeetha Reddy, Lin Xu, Isaac Chan. InteractPrint predicts clinically meaningful interactions between cancer epithelial cells and immune cells: Lessons from a single-cell breast cancer atlas [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 GS5-06.

Abstract OT2-17-01: Phase 1 trial of anthracycline chemotherapy in combination with CD40 agonist and Flt3 ligand in metastatic triple-negative breast cancer

Background: Only a subset of patients with metastatic triple-negative breast cancers (TNBC) demonstrate response to FDA approved PD-1 immune checkpoint blockade (ICB), and few have durable responses. Data suggests that breast cancers have defects in antigen presentation and that antigen presenting cells especially the DC1 subtype of dendritic cells (DCs) are required for response to ICB. CD40 agonists activate antigen presenting cells including DCs and B cells and also repolarize macrophages to an anti-tumor phenotype. Flt3 ligand is a growth factor that increases differentiation and expansion of DCs. We recently demonstrated in pre-clinical TNBC models that the combination of liposomal-doxorubicin chemotherapy, a CD40 agonist, and a Flt3 ligand improves outcomes compared to alternate combinations. Methods: This is a single arm phase I pilot study of liposomal-doxorubicin, CDX-1140 (CD40 agonist), and CDX-301 (Flt3 ligand) combination therapy in patients with metastatic or unresectable locally advanced metastatic TNBC. Patients will be randomized to 3 lead-in arms (triplet therapy, doublet immunotherapy only, or liposomal-doxorubicin only) for 1 cycle prior to receiving triplet therapy with fresh tissue biopsies before and after the lead-in treatment. CDX-301 will be discontinued after 2 cycles; liposomal-doxorubicin and CDX-1140 will be continued until disease progression or clinically limiting toxicities. Primary endpoint is determination of a recommended phase 2 dose based on treatment-related adverse events including dose-limiting toxicities. Secondary endpoints include anti-tumor immune response after triplet therapy, after immunotherapy alone, and after liposomal-doxorubicin alone; median progression-free survival, overall response rate, duration of response, and clinical benefit rate. Key eligibility criteria are unresectable stage III or stage IV TNBC (ER ≤10%, PR ≤10%, HER2/neu negative), 1st to 3rd line metastatic treatment setting (1st line patients need to be PD-L1 negative by 22C3 assay), measurable disease by RECIST 1.1 criteria, consent for pre-treatment and on-treatment biopsies of amenable soft tissue tumor lesions, no prior treatment with an anti-CD40 antibody or a Flt3 ligand, no anthracycline treatment in the metastatic setting, no prior progression while on anthracycline-based therapy or within 6 months of completing neoadjuvant chemotherapy, and no history of non-infectious pneumonitis or current pneumonitis. This trial will enroll up to 45 patients across multiple sites (NCT05029999).

Citation Format: Sangeetha Reddy, Meredith Carter, Isaac Chan, Nisha Unni, Namrata Peswani, Dawn Klemow, Samira Syed, Shahbano Shakeel, Farjana Fattah, Chul Ahn, Yisheng Fang, Heather McArthur, Nicole Sinclair, Michael Yellin, Denise Yardley, Nan Chen, Joyce O’Shaughnessy, Rita Nanda, Suzanne D. Conzen, Carlos Arteaga. Phase 1 trial of anthracycline chemotherapy in combination with CD40 agonist and Flt3 ligand in metastatic triple-negative 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 OT2-17-01.

Abstract 4197: Treatment with chemotherapy, CD40 agonist, and Flt3 ligand triplet combination enhances antigen presentation and leads to cures in triple negative breast cancer

Introduction: Triple negative breast cancers (TNBC) have shown limited responses to immune checkpoint blockade (ICB). Breast cancer is associated with defects in antigen presentation which may contribute to resistance to ICB. Flt3 ligand (Flt3L) is a growth factor that increases differentiation of DC1 dendritic cells, critical mediators of antigen presentation. CD40 agonist activates all 3 classes of antigen presenting cells - dendritic cells, B cells, and macrophages. Synergy has been demonstrated between Flt3L and CD40 agonist as well as between CD40 agonist and chemotherapy in other cancers, however the combination of all three has not been studied in breast cancer.

Methods: 6-8 week old Balb/c mice were injected with 4T1 triple negative breast cancer cells. When tumors were 50 mm3, mice were first treated with intraperitoneal pegylated liposomal doxorubicin (PLD) once and subcutaneous Flt3L daily for 5 days in different sequencing schedules (PLD first followed by Flt3L immediately or 4 days later or Flt3L first followed by PLD 7 days or 10 days later). Based on optimal scheduling of PLD and Flt3L, mice were treated with PLD alone, Flt3L alone, CD40 agonist alone, PLD + Flt3L, PLD + CD40 agonist, PLD + PD-1 blockade, or PLD + CD40 agonist + Flt3L. In addition to serial tumor measurements, mice were sacrificed and tumors and lymphoid organs harvested for flow cytometry analyses.

Results: Treatment with PLD at least 4 days before Flt3L led to an optimal increase in intra-tumoral DC1 cells (p=0.0002), increase in polyfunctional CD8 T cell response (p<0.0001), reduced PD-L1 expression on DC1 cells (p<0.0001), and reduced PD-1 expression on CD8 T cells (p<0.0001) compared to other sequencing schedules. Therefore, this regimen was advanced for further study. Treatment with novel triplet combination of PLD, Flt3L, and CD40 agonist resulted in improved tumor control and survival compared to PLD alone (p<0.0001 and p<0.0001, respectively), Flt3L alone (p<0.0001 and p<0.0001), CD40 agonist alone (p <0.0001 and p<0.0001), PLD + Flt3L (p<0.0001 and p<0.0001), PLD + CD40 agonist (p<0.0001 and p<0.0001), and PLD + PD-1 blockade (p<0.0001 and p<0.0001). 22% of mice were tumor-free in the triplet therapy group only and were resistant to tumor re-challenge. Treatment with triplet therapy was associated with an increase in antigen specific CD8 T cells. Additional mechanistic studies will also be presented.

Conclusions: Novel triplet combination with PLD, CD40 agonist, and Flt3L leads to enhanced tumor control in the 4T1 TNBC mouse model. A clinical trial with this combination in metastatic TNBC patients is expected to begin recruitment soon (NCT05029999).

Citation Format: Vijay Ramani, Shruthi Nooka, Yu-An Zhang, Serena Gibbs, Hai-Cheng Huang, Melanie Hullings, Suzanne Conzen, Carlos L. Arteaga, Isaac Chan, Sangeetha M. Reddy. Treatment with chemotherapy, CD40 agonist, and Flt3 ligand triplet combination enhances antigen presentation and leads to cures in triple negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 4197.

Phase 1 pilot study with dose expansion of chemotherapy in combination with CD40 agonist and Flt3 ligand in metastatic triple-negative breast cancer

TPS1126

Background: Only a subset of patients with metastatic triple-negative breast cancer demonstrate response to currently approved PD-1 immune checkpoint blockade, and few have durable responses. Antigen presentation defects may be a reason for this low response because deficiency of antigen-presenting DC1 dendritic cells is associated with poor anti-tumor immunity. CD40 agonists are a class of agents that activate antigen presenting cells including dendritic cells and B cells and also repolarize macrophages. Flt3 ligand is a growth factor that increases dendritic cells. In line with this, we recently demonstrated in pre-clinical models that the combination of liposomal-doxorubicin chemotherapy, a CD40 agonist, and a Flt3 ligand improves outcomes of breast cancer compared to alternate combinations. Methods: This is a single arm phase I pilot study of liposomal-doxorubicin, CDX-1140 (CD40 agonist), and CDX-301 (Flt3 ligand) combination therapy in patients with metastatic or unresectable locally advanced metastatic triple-negative breast cancer. Patients will be randomized to 3 lead-in arms (triplet therapy, doublet immunotherapy only, liposomal-doxorubicin only) prior to receiving full triplet therapy with fresh tissue biopsies before and after the lead-in treatment. CDX-301 will be discontinued after 2 cycles; liposomal-doxorubicin and CDX-1140 will be continued until disease progression or clinically limiting toxicities. Primary endpoint is determination of a recommended phase 2 dose based on treatment-related adverse events including dose-limiting toxicities. Secondary endpoints include anti-tumor immune response after triplet therapy, after immunotherapy alone, and after liposomal-doxorubicin alone; median progression-free survival, overall response rate, duration of response, and clinical benefit rate. Key eligibility criteria are unresectable stage III or stage IV triple-negative breast cancer (ER ≤10%, PR ≤10%, HER2/neu negative), 1st to 3rd line metastatic treatment setting (1st line patients need to be PD-L1 negative by 22C3 assay), measurable disease by RECIST 1.1 criteria, consent for pre-treatment and on-treatment biopsies of amenable soft tissue tumor lesions, no prior treatment with an anti-CD40 antibody or a Flt3 ligand, no anthracycline treatment in the metastatic setting, no prior progression while on anthracycline-based therapy or within 6 months of completing neoadjuvant chemotherapy, and no history of non-infectious pneumonitis or current pneumonitis. This trial will enroll up to 45 patients across multiple sites. Clinical trial information: NCT05029999.

Population-based targeted sequencing of 54 candidate genes identifies PALB2 as a susceptibility gene for high-grade serous ovarian cancer

PURPOSE

The known epithelial ovarian cancer (EOC) susceptibility genes account for less than 50% of the heritable risk of ovarian cancer suggesting that other susceptibility genes exist. The aim of this study was to evaluate the contribution to ovarian cancer susceptibility of rare deleterious germline variants in a set of candidate genes.

METHODS

We sequenced the coding region of 54 candidate genes in 6385 invasive EOC cases and 6115 controls of broad European ancestry. Genes with an increased frequency of putative deleterious variants in cases versus controls were further examined in an independent set of 14 135 EOC cases and 28 655 controls from the Ovarian Cancer Association Consortium and the UK Biobank. For each gene, we estimated the EOC risks and evaluated associations between germline variant status and clinical characteristics.

RESULTS

The ORs associated for high-grade serous ovarian cancer were 3.01 for PALB2 (95% CI 1.59 to 5.68; p=0.00068), 1.99 for POLK (95% CI 1.15 to 3.43; p=0.014) and 4.07 for SLX4 (95% CI 1.34 to 12.4; p=0.013). Deleterious mutations in FBXO10 were associated with a reduced risk of disease (OR 0.27, 95% CI 0.07 to 1.00, p=0.049). However, based on the Bayes false discovery probability, only the association for PALB2 in high-grade serous ovarian cancer is likely to represent a true positive.

CONCLUSIONS

We have found strong evidence that carriers of PALB2 deleterious mutations are at increased risk of high-grade serous ovarian cancer. Whether the magnitude of risk is sufficiently high to warrant the inclusion of PALB2 in cancer gene panels for ovarian cancer risk testing is unclear; much larger sample sizes will be needed to provide sufficiently precise estimates for clinical counselling.

Abstract PO-033: 'Pull Up A Seat': A program shining a light on the experiences of Black women with breast cancer for healthcare providers and the scientific community

Breast cancer incidence rates for Black women are lower than that of their white counterparts, yet the mortality of Black women is 40 percent higher. Among women under 50, the mortality disparity is even greater: double that of white women. The gap between breast cancer incidence and mortality among Black women is complex and multifactorial. Social, economic, behavioral factors may partially account for the disparity, along with historical and systemic racism causing trauma and mistrust within this community. Black women are also more likely than white women to have inadequate health insurance or access to health care facilities, which may affect access to screening, follow-up care, and completion of treatment. This study measures social, economic and behavioral factors that affect access to adequate healthcare through listening sessions entitled 'Pull Up A Seat: Shining a Light on the Experiences of Black Women with Breast Cancer’. 'Pull Ups' are events in partnership with The Tigerlily Foundation and GRASP, bringing together health equity experts, healthcare providers, scientists, researchers, clinicians and Black women with a history of breast cancer. Each meeting consists of a lecture on broad topics such as racism in medical research, clinical trial exclusion/inclusion criteria and history of mistrust from Black community. After the lecture, breakout rooms led by Black patient advocates are held for healthcare providers with the concept that patients are experts in living with the disease and have much to share – and teach – healthcare providers and researchers. Our methodology will be based on surveys post-event to attendants and an impact report with metrics and teachings to health providers and researchers to determine learning and changes to be made in practices. We believe this program created for and by black patients affected by breast cancer from across diverse and underserved populations will help increase the participation of black women with breast cancer in clinical trials through patient empowerment and health provider awareness of unconscious biases. In addition, we believe this program will result in co-creating solutions to limit barriers for Black women.

Citation Format: Julia Maues, Maimah Karmo, Shanda Cooper, Sheila McGlown, Jamil Rivers, Chawnte Randall, Tania Koulakian, Christine Hodgdon, Isaac Chan. 'Pull Up A Seat': A program shining a light on the experiences of Black women with breast cancer for healthcare providers and the scientific community [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-033.

Impact of the Current US Preventive Services Task Force Recommendations for Cervical Cancer Screening in Young Women 21 to 29 Years Old

OBJECTIVES

In 2012, the US Preventive Services Task Force decreased the recommended frequency of cervical cytology screening to once every 3 years and recommended against testing women younger than 21 years regardless of sexual history. We evaluated the impact of this in 21 to 29-year-old women at a tertiary care academic medical center in 2011 and 2017.

METHODS

We retrospectively analyzed Papanicolaou test results at two time points in 21- to 29-year-old women.

RESULTS

There was a decrease in the number of high-grade lesions in 21- to 25-year-old women (odds ratio [OR], 0.36) from 2011 to 2017. Within the 26- to 29-year-old patient group, there was a trend toward a higher percentage of high-grade squamous intraepithelial lesion (HSIL) in 2017 compared to 2011 on cytology, which did not reach statistical significance (OR, 1.46). However, follow-up histologic specimens showed a higher percentage of HSIL in 2017 compared to 2011 in this age group (OR, 2.16).

CONCLUSIONS

Our findings suggest that the cervical cancer screening guidelines introduced in 2012 have not had a detrimental impact on the outcomes of cervical cancer screening for 21- to 25-year-old women. However, we need to continue monitoring the effects of decreased screening in 26- to 29-year-old women.

Title

Epilepsy is defined as drug-resistant after failure of two adequate trials of appropriately chosen and administered antiepileptic drugs. Approximately 30% of patients with epilepsy have drug-resistant epilepsy. Reasons for treatment failure include failure to recognise epilepsy syndrome, poor drug compliance, and lifestyle factors. Patients with drug-resistant epilepsy should be encouraged to have early referral to a tertiary epilepsy centre for presurgical evaluation. Comprehensive neurophysiology, structural neuroimaging, neuropsychological, and psychiatric assessments are regarded as essential for determining suitability for epilepsy surgery. Epilepsy surgery, whether resection, disconnection, or neuromodulation, should be recommended only after multidisciplinary consensus agreement based on these assessments.

Abstract PD6-03: High prevalence and clonal heterogeneity of ESR1 mutations (mt) in circulating tumor DNA (ctDNA) from patients (pts) enrolled in FERGI, a randomized phase II study testing pictilisib (GDC-0941) in combination with fulvestrant (F) in pts that failed a prior aromatase inhibitor (AI)

Background: Mutations in the ligand binding domain of the estrogen receptor gene (ESR1) have been associated with resistance to AI therapy in pts with ER+ breast cancer. To assess if ESR1 status has prognostic or predictive significance in the post-AI metastatic setting ESR1 mutation status was analyzed in circulating tumor DNA (ctDNA) from 168 pts enrolled on the FERGI study (NCT01437566; Krop et al., SABCS 2014).

Methods: Baseline and longitudinal mutational analysis for hotspot mutations in ESR1 (E380Q, S463P, V534E, P535H, L536R/H/P, L536Q, Y537N/S/C, D538G) and PIK3CA (C420R, E542K, E545K/G, Q546K, M1043I, H1047Y/R/L) was performed using droplet digital PCR (ddPCR) on ctDNA derived from plasma. Archival tissue was analyzed via RT-PCR and ddPCR.

Results: Baseline ctDNA analysis demonstrated a total of 62/156 (40%) and 57/153 (37%) pts with PIK3CA and ESR1 mutations, respectively. The most common ESR1 mutations are D538G, Y537S, and E380Q, representing 54%, 33% and 26% of the pts with a detectable ESR1 mutation at baseline, respectively. There was a numeric increase of ESR1 mutations in patients with LumA (41/99, 41%) vs LumB disease (14/44, 31%). PIK3CA mutations in asynchronously collected archival tissue were 85% concordant with plasma ctDNA mutations (sensitivity 78%, specificity 91%). PIK3CA mutations in baseline ctDNA showed a higher median allele frequency (AF) than ESR1 mutations (3.6% vs 0.46%), consistent with PIK3CA being an early event and ESR1 mutations occurring later in pts with recurrent disease. Of the pts with a detectable ESR1 mutation at baseline (n=57), 23 (40%) pts had multiple ESR1 mutations and 10 (18%) had ≥3 ESR1 mutations. The PFS outcomes for patients with and without ESR1 mutations detected at baseline are summarized below, indicating no obvious prognostic or predictive effect for combination of F with pictilisib compared with F in these underpowered subsets.

ArmESR1 MT - mPFS (mo)ESR1 WT - mPFS (mo)HR (95% CI)F + placebo5.4 (30 pts, 24 events)3.7 (40 pts, 31 events)1.06 (0.62, 1.81)F+pictilisib5.8 (27 pts, 20 events)6.7 (56 pts, 34 events)1.36 (0.78, 2.38)

PIK3CA and ESR1 ctDNA analysis on serial plasma samples from 40 pts and the assessment of ESR1 mutation status in the patient's tumor sample by ddPCR is currently in progress and will be reported.

Conclusions: Mutations in ESR1 detected by ddPCR in patient plasma samples occur in nearly 40% of pts that failed a prior AI. The polyclonal nature of ESR1 mutations is consistent with the convergent evolution of multiple AI resistant subclones. While these conclusions should be interpreted with caution due to the relatively small sample size and post hoc nature of the analysis, this data does not support a prognostic or predictive PFS hypothesis for ESR1 mutations with F or in combination with pictilisib.

Citation Format: Spoerke J, Gendreau S, Johnston S, Schmid P, Krop I, Qui J, Derynck M, Chan I, Walter K, Amler L, Hampton G, Lackner M. High prevalence and clonal heterogeneity of ESR1 mutations (mt) in circulating tumor DNA (ctDNA) from patients (pts) enrolled in FERGI, a randomized phase II study testing pictilisib (GDC-0941) in combination with fulvestrant (F) in pts that failed a prior aromatase inhibitor (AI). [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 PD6-03.

Trichophyton erinacei kerion barbae from a hedgehog with direct osculatory transfer to another person

We describe a case of kerion tinea barbae infection due to Trichophyton erinacei in a 37-year-old man. The infection had also been transferred to his partner by direct contact from kissing. T. erinacei is a zoophilic dermatophyte occasionally harboured by the hedgehog (Erinaceus europaeus). There are few reports of human infection in the literature, and it rarely causes a kerion. There is only one previous report of tinea barbae occurrence due to T. erinacei. This case highlights the possibility of one of the more unusual fungal infections that can be acquired in the UK, and highlights the necessity of asking specific questions to identify possible sources of infection.

Cardiovascular risk and bone loss in men undergoing androgen deprivation therapy for non-metastatic prostate cancer: implementation of standardized management guidelines

Our objective was to evaluate the effectiveness of implementing standardized guidelines to mitigate metabolic and bone side effects of androgen deprivation therapy (ADT) in men with non-metastatic prostate cancer. We conducted a 2-year prospective cohort study at a tertiary referral teaching hospital. Overall, 236 men (mean age 69.8 ± 7.1) commencing ADT for non-metastatic prostate cancer attended a baseline clinic visit between 2007 and 2011, and 153 men were eligible for follow-up after 2 years of continuous ADT. Of these, 113 men had data available for analysis at 2 years. At baseline, 87% of the men were overweight or obese, 61% had hypertension, 56% had hypercholesterolaemia, 27% prior cardiovascular disease, 11% osteoporosis and 40% osteopaenia. After 2 years of ADT, there was an increase in waist circumference (+2.8 ± 6.3 cm, p = 0.002), and, in men without diabetes, in HbA1c (+0.13 ± 0.34%, p = 0.019). Despite this, due to treatment, there were significant reductions in total cholesterol (-0.35 ± 1.00 mmol/L, p < 0.001), and blood pressure (systolic -7.6 ± 19.3 mmHg; diastolic -4.7 ± 11.6 mmHg, p < 0.001). After 2 years, men not receiving anti-resorptive therapy experienced a significant decline in lumbar spine (-0.042 ± 0.134 g/cm(2) , p = 0.012) and total hip bone mineral density (BMD) (-0.026 ± 0.036 g/cm(2) , p < 0.001), whereas bisphosphonate treatment maintained stable BMD. Prevalence of anaemia increased from 13.8 to 32.5%. Older age independently predicted a greater drop in haemoglobin (p = 0.005). We conclude that a structured approach to assess and treat men undergoing ADT effectively improves cardiovascular risk factors and prevents bone decay. Larger studies are needed to determine effects on cardiovascular outcomes, fracture prevention and survival.

Structural and Chemical Microanalysis of Oxygen-Bearing Precipitates in Silicon

Precipitation in CZ-silicon during post-growth two-stage heat treatment has been examined using the methods of high resolution analytical electron microscopy. Electron transparent specimens prepared from these specimens, exhibited a low density of plate type precipitates on {100} planes. Microdiffraction experiments showed the precipitates to be consistently non-crystalline. Electron energy loss spectra showed that the precipitates contained oxygen, but carbon was not detected. It was found that carbon artifact absorption edges could be induced in spectra by specimen contamination in the microscope. The use of a low temperature stage eliminated this problem. Complementary characteristic x-ray microanalysis showed that metallic impurities had not segregated to these precipitates in this particular case, although this has been observed elsewhere.

Ultrasound-guided, percutaneous peripheral nerve stimulation: technical note

BACKGROUND

Peripheral nerve stimulation is a form of neuromodulation that applies electric current to peripheral nerves to induce stimulation paresthesias within the painful areas.

OBJECTIVE

To report a method of ultrasound-guided, percutaneous peripheral nerve stimulation. This technique utilizes real-time imaging to avoid injury to adjacent vascular structures during minimally invasive placement of peripheral nerve stimulator electrodes.

MATERIAL AND METHODS

We describe a patient that presented with chronic, bilateral foot pain following multiple foot surgeries, for whom a comprehensive, pain management treatment strategy had failed. We utilized ultrasound-guided, percutaneous tibial nerve stimulation at a thigh level to provide durable pain relief on the right side, and open peripheral nerve stimulation on the left.

RESULTS

The patient experienced appropriate stimulation paresthesias and excellent pain relief on the plantar aspect of the right foot with the percutaneous electrode. On the left side, we were unable to direct the stimulation paresthesias to the sole of the foot, despite multiple electrode repositionings. A subsequent, open placement of a left tibial nerve stimulator was performed. This revealed that the correct electrode position against the tibial nerve was immediately adjacent to the popliteal artery, and was thus not appropriate for percutaneous placement.

CONCLUSION

We describe a method of ultrasound-guided peripheral nerve stimulation that avoids the invasiveness of electrode placement via an open procedure while providing excellent pain relief. We further describe limitations of the percutaneous approach when navigating close to large blood vessels, a situation more appropriately managed with open peripheral nerve stimulator placement. Ultrasound-guided placement may be considered for patients receiving peripheral nerve stimulators placed within the deep tissues, and not easily placed in a blind fashion.

Age- and sex-specific genomic profiles in non-small cell lung cancer

CONTEXT

Gene expression profiling may be useful in examining differences underlying age- and sex-specific outcomes in non-small cell lung cancer (NSCLC).

OBJECTIVE

To describe clinically relevant differences in the underlying biology of NSCLC based on patient age and sex.

DESIGN, SETTING, AND PATIENTS

Retrospective analysis of 787 patients with predominantly early stage NSCLC performed at Duke University, Durham, North Carolina, from July 2008 to June 2009. Lung tumor samples with corresponding microarray and clinical data were used. All patients were divided into subgroups based on age (< 70 vs > or = 70 years old) or sex. Gene expression signatures representing oncogenic pathway activation and tumor biology/microenvironment status were applied to these samples to obtain patterns of activation/deregulation.

MAIN OUTCOME MEASURES

Patterns of oncogenic and molecular signaling pathway activation that are reproducible and correlate with 5-year recurrence-free patient survival.

RESULTS

Low- and high-risk patient clusters/cohorts were identified with the longest and shortest 5-year recurrence-free survival, respectively, within the age and sex NSCLC subgroups. These cohorts of NSCLC demonstrate similar patterns of pathway activation. In patients younger than 70 years, high-risk patients, with the shortest recurrence-free survival, demonstrated increased activation of the Src (25% vs 6%; P<.001) and tumor necrosis factor (76% vs 42%; P<.001) pathways compared with low-risk patients. High-risk patients aged 70 years or older demonstrated increased activation of the wound healing (40% vs 24%; P = .02) and invasiveness (64% vs 20%; P<.001) pathways compared with low-risk patients. In women, high-risk patients demonstrated increased activation of the invasiveness (99% vs 2%; P<.001) and STAT3 (72% vs 35%; P<.001) pathways while high-risk men demonstrated increased activation of the STAT3 (87% vs 18%; P<.001), tumor necrosis factor (90% vs 46%; P<.001), EGFR (13% vs 2%; P = .003), and wound healing (50% vs 22%; P<.001) pathways. Multivariate analyses confirmed the independent clinical relevance of the pathway-based subphenotypes in women (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.34-3.03; P<.001) and patients younger than 70 years (HR, 1.83; 95% CI, 1.24-2.71; P = .003). All observations were reproducible in split sample analyses.

CONCLUSIONS

Among a cohort of patients with NSCLC, subgroups defined by oncogenic pathway activation profiles were associated with recurrence-free survival. These findings require validation in independent patient data sets.

Progression elevated gene-3 promoter (PEG-Prom) confers cancer cell selectivity to human polynucleotide phosphorylase (hPNPase(old-35))-mediated growth suppression

The poor prognosis of pancreatic cancer patients using currently available therapies mandates novel therapeutics that combine anti-neoplastic potency with toxicity-minimizing cancer specificity. Employing an overlapping pathway screen to identify genes exhibiting coordinated expression as a consequence of terminal cell differentiation and replicative senescence, we identified human polynucleotide phosphorylase (hPNPase(old-35)), a 3',5'-exoribonuclease that exhibits robust growth-suppressing effects in a wide spectrum of human cancers. A limitation to the anti-neoplastic efficacy of hPNPase(old-35) relates to its lack of cancer specificity. The promoter of Progression Elevated Gene-3 (PEG-Prom), discovered in our laboratory via subtraction hybridization in a transformation progression rodent tumor model functions selectively in a diverse array of human cancer cells, with limited activity in normal cells. An adenovirus constructed with the PEG-Prom driving expression of hPNPase(old-35) containing a C-terminal Hemaglutinin (HA)-tag (Ad.PEG.hPNPase(old-35)) was shown to induce robust transgene expression, growth suppression, apoptosis, and cell-cycle arrest in a broad panel of pancreatic cancer cells, with minimal effects in normal immortalized pancreatic cells. hPNPase(old-35) expression correlated with arrest in the G(2)/M phase of the cell cycle and up-regulation of the cyclin-dependent kinase inhibitors (CDKI) p21(CIP1/WAF-1/MDA-6) and p27(KIP1). In a nude mouse xenograft model, Ad.PEG.hPNPase(old-35) injections effectively inhibited growth of human pancreatic cancer cells in vivo. These findings support the potential efficacy of combining a cancer-specific promoter, such as the PEG-Prom, with a novel anti-neoplastic agent, such as hPNPase(old-35), to create a potent, targeted cancer therapeutic, especially for a devastating disease like pancreatic cancer.

Biweekly gemcitabine and oxaliplatin (GEMOX) in first-line metastatic or recurrent nasopharyngeal carcinoma (NPC)—An early report

6071

Background: This multicenter phase II study evaluated the activity & safety of oxaliplatin (Ox), a 3rd generation platinum, in combination with gemcitabine (GEM) for the first time in the palliative setting for patients (pts) with undifferentiated/ poorly differentiated NPC. Methods: Pts with untreated metastatic (M1) or locoregionally recurrent (LR) NPC were treated with a biweekly ‘GEMOX’ regimen (D1: GEM, 1,000 mg/m2 at 10 mg/m2/min; D2: Ox, 100 mg/m2 over 2 hrs) for a max. of 12 cycles. Intrapatient dose escalation of GEM to 1,250 mg/m2 was allowed from cycle 2 onwards if no significant toxicity occurred in cycle 1. Response was assessed every 4 cycles (RECIST criteria). Results: 23 pts accrued before 31st July 06 were evaluated for toxicity & response; cut-off date for data analysis was 15th Oct 06. The median age was 53 yrs (range 38–72); 19 were men, all had ECOG status of 0–1. At enrolment, 7 pts (29%) had M1 disease only, 3 (12%) pts had LR only, & the rest both M1 & LR. All 7 pts with only LR received radical radiotherapy (RT) at initial diagnosis. A median of 11 cycles (range 3–13) were administered. Best overall response rate was 52%, with 12 partial responses & 11 stable diseases. The median duration of response was 7 months (range 0.8–15). Grade (gr) 3–4 hematological toxicities (CTCAE ver 3) included neutropenia in 7 pts (30%, only 1 pt had fever), thrombocytopenia in 5 pts (26%, 1 gr 4 case with mild gum bleeding). Gr 3–4 non-hematological toxicities included gr 3 diarrhoea in 2 pts, gr 4 Ox-related hypersensitivity reaction in 1 pt, gr 3 epistaxis in 2 pts. The commonest non-hematological toxicities were gr 1–2 Ox-related sensory neuropathy (22pts). There were no treatment-related deaths & only 1 pt withdrew from study due to drug-related toxicity. Conclusions: GEMOX is a promising regimen among pts with metastatic & recurrent NPC. Accrual is ongoing with a planned total sample of 40 pts.

No significant financial relationships to disclose.

Illness-related factors, stress and coping strategies in relation to psychological distress in HIV-infected persons in Hong Kong

This study examined the relationships among illness-related factors, stress, coping strategies and psychological distress in HIV-infected persons in Hong Kong (N=118). Multiple regression analyses were used to examine the models of psychological distress as a function of demographic factors, illness-related factors, psychosocial stressors and coping. Results showed that positive thinking was inversely related to psychological distress and avoidance was associated with higher level of anxiety. However, the use of problem solving was found to be inversely related to anxiety. Results are discussed in the context of Chinese culture and the service in Hong Kong.

Safety and immunogenicity of a zoster vaccine in varicella-zoster virus seronegative and low-seropositive healthy adults

OBJECTIVE

To evaluate immunogenicity and tolerability of a live attenuated zoster vaccine in varicella-zoster virus (VZV) seronegative or low-seropositive adults > or = 30 years of age.

STUDY DESIGN

Double-blind, placebo-controlled, randomized, multicenter study. Subjects were enrolled in two stages by prescreened serostatus. Subjects with a low VZV antibody titer (< or = 5 gpELISA units/mL) were enrolled in Stage 1. Subjects with undetecable VZV antibodies and no safety issues identified during Stage 1 were enrolled in Stage 2. All enrolled subjects were randomized 4:1 to receive one dose (approximately 50,000 PFU) of zoster vaccine or placebo and were followed for safety for 42 days postvaccination. Primary objectives/hypotheses: (1) no vaccine-related serious adverse experiences (AE); (2) < or = 1 laboratory-confirmed varicella-like rash with > 50 lesions within 42 days postvaccination.

SECONDARY OBJECTIVE

summarize the VZV antibody response postvaccination.

RESULTS

Twenty-one subjects (age 27 to 69 years; median 34) enrolled (1148 prescreened); 18 (including 4 seronegative subjects) received vaccine and 3 (including 1 seronegative subject) received placebo. Twenty subjects completed the study; one subject withdrew for reasons unrelated to safety. No serious vaccine-related AE or laboratory-confirmed varicella-like rashes with > 50 lesions were reported. In the zoster vaccine group, all 4 of the initially seronegative subjects (age 32 to 36 years; median 33.5) seroconverted and 6 of the 13 (46.2%) initially seropositive subjects had a > or = 4-fold rise in VZV-specific antibody titer at 6 weeks postvaccination.

CONCLUSIONS

The zoster vaccine appears to be immunogenic and generally well tolerated in healthy adults > or = 30 years of age, regardless of initial VZV antibody serostatus.

Clinical and molecular abnormalities in lipoid proteinosis

Lipoid proteinosis (hyalinosis cutis et mucosae) is a rare, autosomal recessive disease. The main clinicopathological features comprise skin and mucous membrane infiltration and scarring with deposition of hyaline material. In this report, we describe a 6-year-old boy in whom a diagnosis of lipoid proteinosis was first suspected when he presented with blisters and erosions at 4 years, a history of life-long dysphonia and a previous epileptic convulsion. The diagnosis was confirmed by histology and identification of a homozygous frameshift mutation, 501insC, in exon 6 of the gene encoding extracellular matrix protein 1, ECM1. Lipoid proteinosis may show protean clinical features and be difficult to diagnose on clinical grounds alone. This case report illustrates that lipoid proteinosis may show protean clinical features and yet remain undiagnosed for many years. Although the gold standard for definite diagnosis remains histology, molecular characterisation of the gene mutation will add to our understanding of genotype-phenotype correlation and perhaps to the development of a rationale for future therapeutics.

Paediatric out-of-hospital cardiac arrests: epidemiology and outcome

INTRODUCTION

Little information is available regarding the outcome of children in our local population who sustained pre-hospital cardiac arrest. This study was performed to determine the survival rate among children after out-of-hospital cardiac arrest, to describe the epidemiology, and to identify predictors of survival.

METHODS

The records of 85 children who presented to a paediatric emergency department in cardiac arrest, between 1 June 1997 and 31 September 2001, were reviewed. The characteristics of the patients, cardiac arrest circumstances, and the outcomes of arrest were analysed.

RESULTS

85 children presented to the emergency department in cardiac arrest during the 52-month study period. 26 out of 85 children (30.6 percent) with cardiac arrest had return of spontaneous circulation (ROSC) after resuscitation efforts at the emergency department. Only four (4.7 percent) survived to be discharged from hospital and three of them survived beyond one year. Two of the cardiac arrest survivors had no change in the neurological status, with the remaining two sustaining severe neurological deficits. Emergency medical service was activated in only 63.7 percent of the patients. 34 percent of the arrests were witnessed, and only 22.9 percent of the children received bystander cardiopulmonary resuscitation (CPR). The positive predictors for survival to hospital discharge in a bivariate analysis were witnessed arrest (p-value is equal to 0.012), presence of bystander CPR (p-value is equal to 0.003), and duration of resuscitation (p-value is equal to 0.028). None who had more than 30 minutes of resuscitation in the emergency department survived. In a multivariate analysis with a logistic regression model, the only two independent predictors of ROSC were witnessed arrest (odds ratio is 3.049; 95% confidence interval [CI] is 1.101-8.444; p-value is equal to 0.032) and duration of resuscitation (odds ratio is 0.353; 95% CI is 0.146 - 0.854; p-value is equal to 0.021).

CONCLUSION

Out-of-hospital cardiac arrest in children has a poor prognosis and prolonged resuscitation at the emergency department beyond 30 minutes does not improve survival.

Multiple dermatofibromas associated with lupus profundus

We report a 58-year-old Afro-Caribbean woman who presented with more than 20 dermatofibromas on the body particularly on the back, arms and legs. These developed spontaneously over the course of 5 years. She also had a long-standing 5 x 2-cm area of lipoatrophy on the right upper arm and a 2-year history of several inflammatory subcutaneous nodules developing on the upper chest and left breast. These were confirmed histologically as lupus profundus. Apart from a mild arthritis, she had no other markers for systemic lupus erythematosus and was systemically well. Multiple dermatofibromas are rare. There are around 30 reports of multiple dermatofibromas associated with systemic diseases. More than half of these cases were associated with systemic lupus erythematosus, with or without systemic steroid therapy and about one-third were associated with HIV infection. Although the mechanism is unknown, it appears that multiple dermatofibromas are associated with autoimmune diseases or altered immune states. This is the first case of multiple dermatofibromas associated with lupus profundus. The knowledge of such associations may contribute to the understanding of the pathogenesis of dermatofibromas, which is as yet unknown.

Rapp-Hodgkin syndrome and the tail of p63

We report the clinical and molecular abnormalities in a 19-year-old woman with Rapp-Hodgkin ectodermal dysplasia syndrome. The physical features include mid-facial hypoplasia, uncombable hair, cleft palate and bifid uvula, lacrimal duct obstruction and dry skin. Sequencing of the p63 gene reveals a new heterozygous frameshift mutation, 1787delG, in exon 14. The frameshift results in changes to the tail of p63 with the addition of 68 missense amino acids downstream and a delayed termination codon that extends the protein length by 21 amino acids. These changes are predicted to disrupt the normal repressive function of the transactivation inhibitory domain leading to gain-of-function for at least two isoforms of the p63 transcription factor. The expanding p63 mutation database demonstrates that there is overlap between Rapp-Hodgkin syndrome and several other ectodermal dysplasia syndromes, notably Hay-Wells syndrome, and that characterization of the functional consequences of these p63 gene mutations at a molecular and cellular level is likely to provide further insight into the clinical spectrum of these developmental malformation syndromes.

Familial multiple cutaneous and uterine leiomyomas associated with papillary renal cell cancer

Multiple cutaneous and uterine leiomyomas is an autosomal dominant condition that results in benign smooth muscle tumours of the skin and, in females, uterine fibroids. This syndrome overlaps with hereditary leiomyomatosis and renal cell cancer syndrome in which affected individuals may develop the rare type II papillary renal cell cancer, in addition to skin leiomyomas. Recently, heterozygous mutations in the gene encoding fumarate hydratase have been found to underlie both conditions. Fumarate hydratase is an enzyme that catalyses the conversion of fumarate to malate in the Kreb's cycle and may also function as a tumour suppressor gene. We report a family with multiple leiomyomas, uterine fibroids and papillary renal cell cancer. The proband is a 77-year-old Polish woman who developed multiple cutaneous leiomyomas on her right upper arm in her thirties and subsequently underwent a hysterectomy for uterine fibroids in her forties. She has four offspring: her eldest daughter also has skin and uterine leiomyomas with a similar onset; her son has multiple skin leiomyomas and in addition was diagnosed with metastatic papillary renal cell cancer at the age of 50 years; the two youngest daughters are unaffected. DNA sequencing in all the affected individuals disclosed a heterozygous G-->C substitution at nucleotide 173 of the fumarate hydratase gene, that converts an arginine residue (CGA) to proline (CCA). This missense mutation has not been reported previously and is designated R58P. Interestingly, the clinically asymptomatic 20-year-old son of the individual with renal cancer was also found to be heterozygous for R58P. It is likely that he will develop skin leiomyomas in the future but the risk of renal cancer is difficult to predict. Nevertheless, detection of this mutation has important implications for screening and genetic counselling in this and other family members.

ADULT ectodermal dysplasia syndrome resulting from the missense mutation R298Q in the p63 gene

Several ectodermal dysplasia syndromes have been shown to result from mutations in the gene that encodes the transcription factor p63. We describe an 11-year-old boy, with clinically normal parents, who had a developmental disorder that resembled EEC (ectrodactyly ectodermal dysplasia-clefting) syndrome (OMIM 604292). He had ectrodactyly and missing middle fingers bilaterally, onychodysplasia, hypodontia with missing teeth, hypohidrosis and lacrimal duct obstruction. DNA sequencing disclosed a heterozygous G-->A substitution at nucleotide 893, that converts an arginine residue (CGA) to glutamine (CAA), the mutation being designated R298Q. This mutation occurs within the DNA-binding domain of p63, and is close to many of the published EEC syndrome mutations. However, R298Q has been described once previously in a large German pedigree, not with EEC syndrome, but another ectodermal dysplasia disorder, ADULT (acro-dermato-ungual-lacrimal-tooth) syndrome (OMIM 103285). Further clinical assessment in our patient revealed that, apart from not having cleft lip and/or palate, he had an exfoliative dermatitis of his hands and feet, and some freckling on his face and shoulders. Collectively, these features support a diagnosis of ADULT syndrome. This study has identified a specific genotype-phenotype correlation in a rare ectodermal dysplasia syndrome and the findings are useful in improving genetic counselling in this family.

Characterization of IgG autoantibodies to extracellular matrix protein 1 in lichen sclerosus

Although the precise aetiology of lichen sclerosus is unknown, evidence for an autoimmune basis to the disorder is emerging. Indeed, circulating IgG autoantibodies to the glycoprotein extracellular matrix protein 1 (ECM1) have been demonstrated in the sera of about 75% of affected individuals. To assess this humoral immune response further, immunoblotting was performed using bacterial recombinant proteins spanning different domains of the ECM1 protein. The aim was to identify autoantibody-reactive sites recognized by 90 lichen sclerosus sera. The subclass distribution of anti-ECM1 IgG autoantibodies was also determined in 54 lichen sclerosus sera. Immunoblotting showed that the IgG autoantibodies from lichen sclerosus patients recognize multiple antigenic reactive sites on the ECM1 protein within both the amino terminus (50/90, 55.6%) and the protein loop cysteine-rich repeat domains (54/90, 60%), although few sera (7/90, 7.8%) had antibodies to the carboxyl terminus of ECM1. IgG subclass analysis revealed that the anti-ECM1 autoantibodies belong predominantly to the IgG(2) subclass (48/54, 88.9%), either IgG(2) alone (28/54, 51.9%) or in combination with one or more other IgG subclasses. No correlation was found between the site(s) of the ECM1 epitopes or the anti-ECM1 IgG profile and any specific clinical parameters. Nevertheless, characterization of anti-ECM1 antibodies does provide further insight into humoral immune responses and understanding disease mechanisms in lichen sclerosus.

Ectodermal dysplasia showing clinical overlap between AEC, Rapp-Hodgkin and CHAND syndromes

The ectodermal dysplasias represent a complex collection of congenital abnormalities of skin, hair, teeth, nail, and sweat gland development, many of which have overlapping clinical features. In this report, we describe a 7-year-old girl, born to clinically normal parents, with ankyloblepharon, cleft lip/palate and hair abnormalities, features resembling the autosomal dominant disorder, ankyloblepharon-ectodermal dysplasia-clefting (AEC) syndrome, which results from mutations in the sterile-alpha motif domain of the gene encoding the transcription factor, p63. However, direct sequencing of the p63 gene in this individual did not reveal any pathogenic sequence variants. Moreover, two of her paternal cousins were discovered to have similar congenital ectodermal anomalies, raising the alternative possibility of an autosomal recessive pattern of inheritance. Furthermore, all affected individuals lacked a history of erosive scalp dermatitis that is usually characteristic of AEC syndrome. Instead, the scalp hair was coarse and wiry. In addition, another atypical feature, hypohidrosis, was present. Collectively, the clinical features also resembled Rapp-Hodgkin syndrome, Bowen-Armstrong syndrome and CHAND syndrome, but did not appear to fit neatly with any one particular disorder. This case highlights the difficulties in trying to classify the ectodermal dysplasia syndromes on clinical features alone.

Clinical and molecular characterization of lipoid proteinosis in Namaqualand, South Africa

BACKGROUND

Lipoid proteinosis (LiP) is a rare autosomal recessive disorder characterized by a hoarse voice, warty skin infiltration and scarring. Mutations within the extracellular matrix protein 1 (ECM1) gene cause LiP. Since the early 1970s it has been recognized that South Africa has one of the largest groups of LiP patients worldwide, suggesting a probable founder effect. As LiP patients present with considerable clinical variability, this group of patients offers a unique opportunity for genotype-phenotype correlation.

OBJECTIVES

To assess the clinical features and the molecular basis of LiP in patients from the Namaqualand area of the Northern Cape province of South Africa and to examine molecular evidence for a founder effect.

SUBJECTS AND METHODS

The LiP patient cohort consisted of 29 Coloured patients from Namaqualand and a further seven Caucasoid patients from other areas of South Africa. The control group included 100 healthy geographically and ethnically matched individuals from Namaqualand. Samples were collected after informed consent and with ethics committee approval from the University of the Witwatersrand. LiP patients were examined clinically and a structured recording sheet was completed. A brief neurological evaluation was also performed. The LiP founder effect was investigated at the molecular level by ECM1 mutation detection and haplotype analysis.

RESULTS

The most consistent clinical signs for a diagnosis of LiP in this group were a hoarse voice and thickened sublingual frenulum leading to restricted tongue movement. Homozygosity for a nonsense mutation in exon 7 of the ECM1 gene, Q276X, was identified in all patients (Coloured and Caucasoid). Despite this genetic homogeneity, considerable clinical variability in skin presentation and psychiatric involvement was observed. Haplotype analysis using markers from a 9.98-Mb region around the ECM1 locus confirmed the founder effect with a founder core haplotype, 19-Q276X-12 (ND1-ECM1-D1S2343), in all but four LiP-associated alleles (n = 58). A LiP carrier rate of 1 in 9 was observed among the 100 Namaqualand controls, predicting a LiP incidence of 1 in 324 in this community.

CONCLUSIONS

Although several consistent clinical features in LiP patients homozygous for the Q276X mutation in the ECM1 gene were observed, there remains considerable clinical variability. This suggests the action of genetic and environmental modifiers of disease severity. Strong molecular evidence supports a single founder effect for the high prevalence of LiP in South Africans, both Coloured and Caucasoid.