Abstract P5-15-01: The use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer reduces false positives, costs, and time to treatment: A multicenter value analysis in the I-SPY2 trial

Introduction: Diagnostic metastatic staging imaging (SI) for asymptomatic stage I-II patients (pts) is not routinely recommended, but is warranted in stage II-III pts with high risk biological subtypes, where previous trials have shown up to a 15% rate of de novo metastatic disease. NCCN guidelines endorse CT CAP and bone scan (STD) for stage III pts, but not PET/CT, and PET/CT is not covered in most parts of the country. We present data on the performance and value of PET/CT.

Methods: Data were available for 799 high risk clinical stage II-III pts screened for I-SPY2 at UCSF, Uminn, UAB, and Georgetown. Of these, 564 pts ranging in age from 25-81 (median = 48) had complete records that were retrospectively reviewed for SI and potential false positives (FP), defined as incidental findings on SI proven benign by subsequent workup. Economic evaluation was conducted from the payer perspective using the mean national 2018 Medicare Physician Fee Schedule and representative costs from the UCSF billing department. The incremental cost effectiveness ratio (ICER) measured the cost of using PET/CT per percent patient (pt) who avoided a FP.

Results: The rate of de novo metastatic disease was 4.8% (38/799), range 3.6-6.4%. Of the 564 pts with complete records, diagnostic SI varied significantly among the four sites (p < 0.0001). STD was used for most pts at UAB (92.8%, 141/152) and Georgetown (85.7%, 54/63), while PET/CT was used for most pts at UCSF (86.6%, 226/261) and Uminn (63.6%, 56/88). Chest X-ray was used for 29.5% (26/88) at Uminn. There were significantly more pts with FP in the group that received STD (22.1%, 51/231) vs. PET/CT (11.1%, 33/298) (p < 0.05). Mean time between incidental finding on SI to determination of FP was 10.8 days. When controlling for institution, mean time from cancer diagnosis to initiation of neoadjuvant chemotherapy was significantly different between STD (44.3 days) and PET/CT (37.5 days) groups (p < 0.05). When aggregating the four sites using mean costs from the 2018 Medicare Physician Fee Schedule, the mean cost/pt was $1132 for STD vs. $1477 for PET/CT. The mean increase in price from baseline SI costs due to FP workup was $216 (23.6%) for STD vs. $65 (4.6%) for PET/CT. The ICER was $31 per percent pt who avoided a FP. When analyzing UCSF pts alone using representative reimbursements from Medicare, the mean cost/pt was $1236 for STD vs. $1081 for PET/CT; using representative reimbursements from Anthem Blue Cross, the mean cost/pt was $3080 for STD vs. $1662 for PET/CT. The ICERs were -$10 and -$95 per percent pt who avoided a FP, respectively.

Conclusion: As compared to STD metastatic staging workup, PET/CT added value by decreasing FP two-fold. This reduced direct costs of FP workup procedures that took a mean time of 10.8 days to resolve. PET/CT also accelerated treatment start. Reducing the chance of FP workup for metastatic disease is of enormous value to pts. Our data establish the value of PET/CT for staging in our high risk clinical stage II-III trial population and highlight the need for alignment between hospital pricing strategies and payer coverage policies in order to deliver high value care to pts.

Citation Format: Hyland CJ, Varghese F, Yau C, Beckwith H, Khoury K, Varnado W, Hirst G, Chien J, Yee D, Isaacs C, Forero-Torres A, Esserman L, Melisko M, I-SPY2 Consortium. The use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer reduces false positives, costs, and time to treatment: A multicenter value analysis in the I-SPY2 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-15-01.

Abstract OT3-04-01: Nivolumab or capecitabine or combination therapy as adjuvant therapy for triple negative breast cancer (TNBC) with residual disease following neoadjuvant chemotherapy: The OXEL study

Background: Long-term follow-up of neoadjuvant studies demonstrates poor clinical outcomes in patients with TNBC who do not achieve pathologic complete response, with only 35% remaining free of recurrence at 10 years. The addition of adjuvant capecitabine in the CREATE-X study prolonged disease free survival and overall survival (OS) in patients with HER2 negative breast cancer with residual invasive disease, with more striking benefit in patients with TNBC. Checkpoint inhibitors have not been approved in breast cancer yet, but recent studies suggest a benefit in combination with chemotherapy and low burden of disease. In the current study, we will evaluate the role of chemoimmunotherapy in the adjuvant setting for patients with TNBC with residual disease after neoadjuvant therapy. We will also investigate the role of the peripheral immunoscore (PIS) in predicting the benefit of immune checkpoint inhibition with or without chemotherapy.

Trial design: OXEL is a pilot open-label three arm randomized study of nivolumab, capecitabine or the combination as adjuvant therapy for 45 patients with residual TNBC after adequate neoadjuvant chemotherapy. Patients enrolled will be randomly assigned to 1 of 3 treatment arms: nivolumab 360 mg iv q3weeks for x 6 cycles; capecitabine 1250mg/m2 po bid D1-D14 q3 weeks x 6 cycles; nivolumab 360mg iv q3weeks + capecitabine 1250mg/m2 po bid D1-D14 q3 weeks x 6 cycles.

Main eligibility criteria: Patients ≥18 years of age with TNBC and ≥1cm of residual disease in the breast and/or node positive disease; receipt of neoadjuvant taxane +/- anthracycline, or platinum, and having completed definitive resection of primary tumor, with no prior use of capecitabine, fluorouracil or immunotherapy, and with no active autoimmune disease or chronic use of systemic steroids.

Specific aims: The primary endpoint is assessing the immunologic effects of capecitabine, nivolumab or the combination in the adjuvant setting by PIS. Additional endpoints include toxicity assessment, distant recurrence free survival (DRFS) and OS at 3-years, association between changes in PIS and circulating tumor DNA at different timepoints with clinical outcome variables and characterization of the immune contexture in residual tumors.

Statistical methods: The study is designed to assess the change in PIS at 6 weeks from baseline in each arm. The sample size of 15 per arm (45 total for 3 arms) will provide preliminary results. A sample size of 15 per arm will have 85% power to detect an effect size of 1 (the difference of the change in PIS from baseline to week 6 between two arms divided by the standard deviation) at 5% significance level.

Present accrual and target accrual: The Institutional Review Board at Georgetown University Medical Center has approved the study. Clinicaltrials.gov NCT03487666. Enrollment of the first patient is expected in July 2018 with a total of 45 patients planned to be recruited. Recruitment sites are MedStar Georgetown University Hospital, MedStar Washington Hospital Center, Hackensack University Medical Center. This trial is supported by Bristol-Meyers Squibb, P30CA051008-25 from NCI, Inivata and the Nina Hyde Center for Breast Cancer Research.

Citation Format: Khoury K, Isaacs C, Gatti-Mays ME, Donahue RN, Schlom J, Wang H, Gallagher C, Graham D, Warren R, Dilawari A, Swain SM, Pohlmann PR, Lynce F. Nivolumab or capecitabine or combination therapy as adjuvant therapy for triple negative breast cancer (TNBC) with residual disease following neoadjuvant chemotherapy: The OXEL study [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 OT3-04-01.

Leuckart-Wallach Route Toward Isocyanides and Some Applications

Isocyanide-based multicomponent reactions (IMCR) are among the most important chemical reactions to efficiently generate molecular diversity and have found widespread use in industry and academia. Generally, isocyanides are synthesized in 1-2 steps starting from primary amines. Here, we provide experimental detail on an alternative approach toward formamides and, thus, isocyanides via the Leuckart-Wallach reaction in an improved variation. The resulting >50 synthesized and characterized formamides are useful starting materials for IMCR, as well as other chemistries. The advantage of using the Leuckart-Wallach pathway to formamides and isocyanides is the lower price, on average, of the starting materials, as well as their differential and complementary structural diversity, as compared to the primary amine pathway.

MCR synthesis of a tetracyclic tetrazole scaffold

Scaffold diversity is key in the ongoing exercise of discovery of novel bioactive compounds using high throughput screening (HTS). Based on the Ugi tetrazole synthesis we have designed novel bi- and tri-cyclic scaffolds featuring interesting pharmacophore properties. The compounds of the scaffold (B) are synthesizable in large diversity and numbers in two steps using (hetero)phenylethylamines, HN3, oxo components and iscyanoacetaldehyde(dimethylacetale). The chemistry is amenable to parallel synthesis and is used to enhance and fill the screening decks of the European Lead factory (ELF). Here, we are reporting full experimental details, scope and limitations of the reaction, cheminformatic analysis and the 3D structures of selected compounds.

Concise Synthesis of Tetrazole-keto-piperazines by Two Consecutive Ugi Reactions

A concise route for the synthesis of the novel compound class tetrazole–diketopiperazines was developed. The approach involves the use of two multicomponent reactions: the Ugi tetrazole four‐component reaction (4CR) and the classical intramolecular Ugi 4CR. The tetrazole–diketopiperazines comprise analogs of and are bioisosteric to bioactive diketopiperazines, which thus draws attention for novel bioactive compound design. This scaffold was produced to fill the screening deck of the European lead factory.

A universal isocyanide for diverse heterocycle syntheses

Novel scaffolds are of uttermost importance for the discovery of functional material. Three different heterocyclic scaffolds easily accessible from isocyanoacetaldehyde dimethylacetal 1 by multicomponent reaction (MCR) are described. They can be efficiently synthesized by a Ugi tetrazole multicomponent reaction of 1. We discuss the synthesis, 3D structures, and other physicochemical properties.

Discovery of highly potent p53-MDM2 antagonists and structural basis for anti-acute myeloid leukemia activities

The inhibition of p53-MDM2 interaction is a promising new approach to non-genotoxic cancer treatment. A potential application for drugs blocking the p53-MDM2 interaction is acute myeloid leukemia (AML) due to the occurrence of wild type p53 (wt p53) in the majority of patients. Although there are very promising preclinical results of several p53-MDM2 antagonists in early development, none of the compounds have yet proven the utility as a next generation anticancer agent. Herein we report the design, synthesis and optimization of YH239-EE (ethyl ester of the free carboxylic acid compound YH239), a potent p53-MDM2 antagonizing and apoptosis-inducing agent characterized by a number of leukemia cell lines as well as patient-derived AML blast samples. The structural basis of the interaction between MDM2 (the p53 receptor) and YH239 is elucidated by a co-crystal structure. YH239-EE acts as a prodrug and is the most potent compound that induces apoptosis in AML cells and patient samples. The observed superior activity compared to reference compounds provides the preclinical basis for further investigation and progression of YH239-EE.

Transient protein states in designing inhibitors of the MDM2-p53 interaction

Reactivation of p53 by release of the functional protein from its inhibition by MDM2 provides an efficient, nongenotoxic approach to a wide variety of cancers. We present the cocrystal structures of two complexes of MDM2 with inhibitors based on 6-chloroindole scaffolds. Both molecules bound to a distinct conformational state of MDM2 with nM-μM affinities. In contrast to other structurally characterized antagonists, which mimic three amino acids of p53 (Phe19, Trp23, and Leu26), the compounds induced an additional hydrophobic pocket on the MDM2 surface and unveiled a four-point binding mode. The enlarged interaction interface of the inhibitors resulted in extension of small molecules binding toward the "lid" segment of MDM2 (residues 19-23)--a nascent element that interferes with p53 binding. As supported by protein engineering and molecular dynamics studies, employing these unstable elements of MDM2 provides an efficient and yet unexplored alternative in development of MDM2-p53 association inhibitors.

Various cyclization scaffolds by a truly Ugi 4-CR

Efficient access to a large chemical space based on new scaffolds with defined 3D conformations and highly variable in the side chains is needed to find novel functional materials. Four heterocyclic scaffolds based on a four component Ugi reaction of α-amino acids, oxo components, isocyanides and primary or secondary amines suitably functionalized are described. A handful of examples are described for each scaffold.

Tricycles by a new Ugi variation and Pictet-Spengler reaction in one pot

Subsequent mild cyclization of aromatic substrates by Pictet-Spengler condensation stereoselectively gave new tricyclic compounds. Examples are described in decent yields over two steps in one pot, and a crystal structure is also presented to support the proposed structures.

P53 mdm2 inhibitors

The protein-protein interaction (PPI) between p53 and its negative regulator MDM2 comprises one of the most important and intensely studied PPI's involved in preventing the initiation of cancer. The interaction between p53 and MDM2 is conformation-based and is tightly regulated on multiple levels. Due to the Angstrom level structural insight there is a reasonable understanding of the structural requirements needed for a molecule to bind to MDM2 and successfully inhibit the p53/MDM2 interaction. The current review summarizes the binding characteristics of the different disclosed small molecules for inhibition of MDM2 with a co-crystal structure. Synthetic access to these compounds as well as their derivatives are described in detail.

Multicomponent synthesis of diverse 1,4-benzodiazepine scaffolds

The 1,4-benzodiazepine (BDZ) scaffold is of particular interest in drug design due to a balanced ensemble of beneficial physicochemical properties including a semirigid and compact diazepine ring with spatial placements of several substituents, combined with low number of rotatable bonds, hydrogen bond donors and acceptors, and intermediate lipophilicity. As an alternative to traditional multistep sequential syntheses, we designed routes employing one-pot MCRs to accelerate access diverse BDZ scaffolds in two or three steps.

The p53-MDM2/MDMX axis - A chemotype perspective

The protein-protein interaction (PPI) of the tumor suppressor p53 and its negative regulator MDM2 consists of the most intense studied PPI with a group of small molecular weight antagonists described and many more disclosed in patent literature. Due to the Å-level structural insight into p53 interaction with MDM2 there is a reasonable understanding of the requirements of the molecules to bind. In contrast and despite the very close homology and 3-D similarity no potent MDMX antagonist has been disclosed up to date. The current review summarizes the different disclosed chemotypes for MDM2 including a discussion of the cocrystal structures. Structures and approaches to reconstitute functional p53 from mutated p53 are presented. Finally new screening methods and recent biotech deals based on p53 are discussed.

[Acutely ruptured intracranial aneurysms treated with GDC coils. Results from a single center over a period of 5 years]

PURPOSE

We prospectively reviewed the clinical results of acutely ruptured cerebral aneurysms treated with GDC over a 5 year period, in order to characterize death and dependency factors.

METHODS

Between 1997 and 2002, 229 patients (254 aneurysms treated, 140 females, 89 males; mean age: 51 years) with aneurysmal subarachnoid hemorrhage were treated with GDC (Boston Scientific Neurovascular, Fremont, CA) once the anatomical conditions of feasibility had been achieved. Over 90% of the aneurysms treated (mean size: 5,8 mm) were located in the anterior circulation. The anterior communicating artery complex (87 cases), the posterior aspect of the internal carotid artery (65 cases), and the middle cerebral artery (49 cases) were most commonly treated.

RESULTS

At the end of the initial hospitalization period, 14 patients (6.1%) died. Major procedural complications were associated with perforation of the aneurysmal sac in 9 patients (3.9%), thromboembolic events in 10 patients (4.3%) which resulted in 2 deaths (0.8%) and permanent neurologic morbidity in 7 patients (3%). The univariate analysis demonstrated no correlation between death and time-to-treatment, the topography of the aneurysm, or the occurrence of treatment related complications. The results of the logistical regression model demonstrated that the clinical score upon entry, and the occurrence of delayed ischemia were the only independent factors correlated with patient death. The prognostic factors affecting the degree of sequellae identified by the logistical regression model were the clinical score upon admission, age, treatment related complications, and pulmonary complications.

CONCLUSIONS

Endovascular treatment of ruptured anterior circulation aneurysms with GDC, including MCA aneurysms, is associated with low morbidity and allows good overall outcomes in patients with subarachnoid hemorrhage. A better understanding of dependency factors associated with endovascular coiling will foster further technical advances in order to improve the treatment of small and medium sized ruptured aneurysms.

[Muscular manifestations in periodic disease]

Between 1976 and 1983, the authors studied 50 new patients affected with periodic disease. 16 of them-mean age: 29-presented muscular manifestations. They may be grouped into two clinical aspects: muscular pain and contractures. The authors consider that these symptoms, first described in 1945, are an inherent part of the clinical picture of the disease. They discuss their relationship with periarteritis nodosa and remind the fact that their pathogenesis remains unknown.

Cerebral hypoxia from bicarbonate infusion in diabetic acidosis

To study the delivery of oxygen to the cerebral tissue during metabolic acidosis and its therapy with bicarbonate (NaHCO3), oxygen partial pressure of the cisternal fluid was measured in 12 experiments of HCl-induced acidemia and eight experiments of diabetic ketoacidosis in 16 unanesthetized dogs. Full correction of acidosis with bicarbonate caused a significant (P less than 0.05) decrease in Pcsf 2: in the HCl acidotic dogs, Pcsfo2 decreased from 53.9 +/- 2.2 torr to 45.9 +/- 2.3 torr within one hour; in the ketoacidotic dogs, Pcsfo2 decreased for 48.5 +/- 5.4 torr to 26.7 +/- 6.6 torr within six hours. In the ketoacidotic dogs not treated with bicarbonate, there was no significant change in Pcsfo2. An inverse relationship (P less than 0.01) between the cisternal lactic acid level and the cisternal PO2 was also observed. It is concluded that NaHCO3 therapy in diabetic ketoacidosis decreases the cerebral O2 availability and that cerebral hypoxia contributes to the brain dysfunction encountered after the initiation of such therapy in acidemia.

The measurement of volatile chromium in biological materials

Chromium is an essential trace element in mammals since dietary chromium deficiency results in glucose intolerance due to decreased sensitivity to insulin. In humans, both adults and children with glucose intolerance have been improved by treatment with chromium. Furthermore, chromium deficiency has been implicated as a causative factor in hypercholesterolemia and atherosclerosis. However, little is known of the metabolism of chromium in humans, primarily because of analytical difficulties. The biologically active form of chromium is the "glucose tolerance factor" (GTF) which is a co-ordination complex of trivalent chromium with nicotinic acid and certain amino acids. At physiological pH, ionic chromium as a simple inorganic salt is insoluble in water, but trivalent chromium forms stable complexes with ascorbic acid, amino acids and other substances present in blood and tissue. Chromium is present in serum, bound to protein and also as dialysable or ultrafiltrable chromium (free chromium). The free chromium includes G.T.F. and other coordination complexes and represents the metabolically active form of the element; the ratio free/protein bound chromium in serum varies within the individual according to the diet and the metabolic state.

Glucose and insulin metabolism in Friedreich's ataxia

Our prospective survey of 50 ataxic patients confirms the previous finding of frequent clinical or chemical diabetes in Friedreich's ataxia. Eighteen percent of our typical cases have clinical diabetes and 40% at least an abnormal glucose tolerance curve. However, this finding does not appear to be specific to that form of ataxia. Furthermore, we have shown that most patients with ataxia have normal or low fasting insulin levels, but a hyperinsulinic response to a glucose load.

[Periodic disease (familial paroxysmal polyseritis). 52 cases]

On the basis of well defined diagnostic criteria, the authors conclude that periodic disease affects males in particular. It commences before the age of 20 years in 80 percent of cases. In particular it occurs in Armenian and Shiite communities. Its evolution is normally benign ; amyloidosis is found in only 8 percent of cases. Joint manifestations are found in 48 percent of cases and may take on different aspects and occur in several different sites : myaglia or arthralgia, monoarthitis, oligoarthritis, polyarthritis, neck or sacroiliac pain. The authors have not noted prolonged peripheral joint episodes. No cases of amyloidosis were diagnosed before the appearance of the clinical signs of the disease. An autosomal, dominant heredity with incomplete penetration seems to be the most likely hypothesis.

Preliminary report on a mass screening program for neonatal hypothyroidism

We have recently developed an immunoassay that can measure thyroxine rapidly and accurately in the eluate of 40 mul of dried blood spotted on filter paper at the fifth day of life. The method is completely automated and by using the samples received by the Central Laboratory of the Quebec Network for Genetic Medicine and their follow-up facilities, we are now screening every newborn in the province of Quebec for neonatal hypothyroidism. To date, from 47,000 measurements, three newborn infants with abnormally low TBG and seven hypothyroid infants have been detected. From these data we conclude that the frequency of congenital hypothyroidism is about one in 7,000 births and that our method is effective in detecting thyroid hormone abnormalities with an acceptable percentage of false positive measurements; no false negative results have occurred to our knowledge.