A case of solitary kidney with duplex collecting systems and renal vascular variants in an adult male cadaver

We describe a unique solitary kidney with duplex collecting system and vascular variation observed in an 86-year-old white male formaldehyde- and phenol-fixed cadaver during routine academic dissection. The left renal fossa was empty with an intact adrenal gland, and the right renal fossa contained a fused renal mass with apparent polarity between the superior and inferior regions and two renal pelves converging into a single ureter. There were three right renal arteries supplying the renal mass; the superior and middle arteries were noted to be postcaval and the inferior artery was precaval. There were also two right renal veins draining into the inferior vena cava and following a regional distribution with the superior vein draining the inferior portion of the renal mass. Despite generally being asymptomatic, the detection of renal anatomical variants is clinically important for appropriate patient management and surgical interventions.

Abstract P6-18-39: Abemaciclib after prior palbociclib exposure in patients with metastatic hormone-receptor positive (HR+)/HER2- breast cancer

Introduction: The advent of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) has transformed the clinical practice of HR+/HER2- metastatic breast cancer. Palbociclib, ribociclib, and abemaciclib have been approved in conjunction with anti-estrogens, while abemaciclib has also been approved as monotherapy based on single agent activity in the MONARCH-1 trial (objective response rate/ORR: 19.7% and median progression-free-survival/PFS = 6.0 months; Dickler M et al CCR 2017). However, there is limited insight into the mechanisms governing resistance to CDK 4/6i and the potential utility of continued CDK4/6i after progression on a prior CDK 4/6i-based therapy.

Methods: We evaluated the clinical outcomes of patients with metastatic HR+/HER2- breast cancer who had received abemaciclib following an initial course of palbociclib-based therapy at our institution. In addition, we conducted genomic analysis utilizing next-generation sequencing of tissue samples and blood (cell-free DNA/cfDNA analysis) where available.

Results: From June, 2014 through July, 2018, a total of 49 patients received abemaciclib, and 14 patients had prior palbociclib exposure. One patient was deceased shortly after initiating abemaciclib and one patient was lost to follow-up. Among the 12 remaining patients, eight had sequential courses of CDK4/6-based therapy, while four patients had at least one intervening non-CDK 4/6i based regimen. At data-cutoff of 8/15/2018, five patients (41.7%) had early progression on abemaciclib (PFS equal to or less than 120 days) while three (25%) patients had ongoing benefit (PFS greater than 120 days, two of three actively on therapy). Three additional patients had recently initiated abemaciclib therapy (less than 120 days prior to current analysis). Preliminary analysis of baseline cfDNA results in patients with early progression on abemaciclib therapy after prior CDK4/6i revealed the presence of RB1 mutation, FGFR1 amplification, and TP53 mutation, among others. Additional analyses with mature clinical data (including updated PFS and ORR), toxicity assessment during secondary CDK4/6i exposure, and further analysis of genomic sequencing results will be provided at the meeting.

Conclusions: The majority of patients had early disease progression on abemaciclib after prior exposure to CDK4/6i suggesting potential cross-resistance to CDK4/6i mediated by common drivers. However, a subset of patients derived clinical benefit with continued exposure to CDK4/6i, highlighting the need for additional research to evaluate potential predictive biomarkers and guide rational utilization of continued CDK4/6 blockade in metastatic HR+/HER2- breast cancer.

Citation Format: Wander SA, Spring LM, Stein CR, Yuen M, Zangardi M, O'Shaughnessy J, Bardia A. Abemaciclib after prior palbociclib exposure in patients with metastatic hormone-receptor positive (HR+)/HER2- breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-39.

Abstract P4-08-08: Genomic progression, detected by circulating tumor DNA (ctDNA) sequencing, as an early predictor of disease progression in metastatic breast cancer (MBC)

Background: The availability of multiple therapies has transformed the landscape of MBC, but also brought the challenge of selecting the right therapy for an individual patient. Furthermore, in patients with Hormone Receptor positive (HR+) breast cancer who have bone metastases only it may be difficult to assess effectiveness of therapy via imaging. Peripheral ctDNA detection and analysis by next-generation sequencing (NGS) has gained popularity in cancer diagnosis and therapeutics due to its relative noninvasiveness, ease of use, and high sensitivity. Here, we explore the utility of ctDNA change as a predictor for disease progression in MBC. We hypothesized that genomic progression is a harbinger of subsequent radiologic progression in patients with MBC.

Methods: We analyzed change from pre-treatment (baseline) to on-treatment ctDNA mutant allele fraction (MAF) among patients with MBC. Patients receiving standard-of-care therapies or investigational agents on clinical trials at our institution were included. All patients were followed from the date of baseline test until death or data cutoff (6/20/2018). All peripheral blood specimens were collected and analyzed between 1/7/2016 and 3/1/2018 via NGS (Guardant360®). Peripheral blood specimens were sequenced prior to initiation of a new therapeutic regimen (baseline) and subsequently at least once while on-treatment, on average 4-12 weeks later. All patients had a follow-up CT scan of chest, abdomen and pelvis 2-4 weeks after the on-treatment NGS. A priori, we defined genomic progression as increase in ctDNA total MAF of at least 20% from baseline. We utilized Cox regression analysis to identify whether genomic progression was a predictor of radiologic progression, adjusting for common prognostic variables.

Results: All patients (N= 77) were female, predominantly White (83.1%), and median age was 57 (range 32 to 77). Fifty one out of 77 patients (66.2%) were ER+, 5 HER2+, and 9 had triple negative breast cancer. The median MAF at baseline was 2.2% (range 0% - 61.7%). Common genomic alterations in ctDNA included PIK3CA, TP53, ESR1, AKT1, NF1. 27 out of 77 (35%) patients showed disease progression on the first subsequent CT scan, while 59 out of 77 (76.6%) progressed during the follow up time. We found that an increase in ctDNA MAF of at least 20% was a strong predictor of disease progression (HR =2.46, CI [1.14-5.32], p=0.02), compared to those who had a MAF increase of less than 20% or a decrease in total MAF. In multi-variable analysis, adjusting for age, number of prior therapies, type of therapy, and visceral metastases, increase in ctDNA remained a significant predictor for subsequent disease progression (HR =3.84, CI [1.63-9.07], p=0.002). Subset results in patients with bone metastases only, and relative comparison of ctDNA with standard tumor markers will be presented at the meeting.

Conclusions: Genomic progression, identified by an increase in ctDNA MAF, is potentially an early predictor of subsequent disease progression in patients with MBC. Further research is needed to prospectively evaluate the clinical utility of ctDNA change as a surrogate marker in guiding treatment decision-making for patients with MBC.

Citation Format: Velimirovic M, Juric D, Niemierko A, Spring LM, Vidula N, Malvarosa G, Yuen M, Moy B, Isakoff SJ, Ellisen LW, Bardia A. Genomic progression, detected by circulating tumor DNA (ctDNA) sequencing, as an early predictor of disease progression in metastatic breast cancer (MBC) [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 P4-08-08.

Abstract P4-01-06: Comparison of tumor genotyping and cell-free circulating tumor DNA sequencing in metastatic breast cancer patients and their utility in the selection of matched therapy

Background: Oncogenic mutations are potential targets for therapeutic intervention in metastatic breast cancer (MBC). While tumor genotyping (TG) has been viewed as the gold standard for identifying oncogenic mutations, cell-free circulating tumor DNA (cfDNA) is emerging as an alternate technique. We previously reported the selection of matched therapy targeted to an actionable mutation based on either TG or cfDNA testing (Vidula N, ASCO, 2018). Therefore, we are now comparing TG and cfDNA results in MBC patients undergoing both tests to examine their relative utility in the selection of matched therapy.

Methods: Patients with MBC at an academic institution who underwent both TG (Next Generation Sequencing/NGS, institutional platform, 104 gene assay) and cfDNA testing (NGS/Guardant360, 73 gene assay) between 1/2016-10/2017 were identified. A chart review was conducted to identify tumor subtype, demographics, treatment, TG and cfDNA results, and clinical outcomes. The relative utility of these tests in the selection of matched therapy was determined, and linked with clinical outcomes (progression-free survival and overall survival).

Results: Thirty patients who underwent both TG and cfDNA testing were identified. The median age was 60 years, the majority (97%) had hormone receptor (HR) positive/HER2 negative disease, and most patients had recurrent disease (83.3%) at MBC diagnosis. The median number of therapies prior to obtaining either test was 1 (cfDNA range 0-9, TG range 0-8). The majority had simultaneous cfDNA and tumor genotyping testing (83.3%) versus sequential testing (16.7%). Twenty-four (80%) patients had actionable mutations detected by cfDNA compared to 19 (63.3%) patients with actionable mutations detected by TG. The median number of actionable mutations detected by cfDNA was 2 (range 0-11) compared with a median of 1 (range 0-4) detected by TG. Failure of TG occurred in 2 of 30 patients (6.7%) but no test failures were seen with cfDNA. Eleven of 30 patients (36.7%) had ≥ 1 concordant mutation via cfDNA and TG. Altogether, 12 out of 30 (40%) patients received matched therapy, 5 of which were based on cfDNA actionable mutations alone (ESR1, ERBB2, CCND1, and PIK3CA), and 7 based on cfDNA and TG results (ESR1, PIK3CA, STK11, and BRCA). Twelve of 24 (50%) patients with actionable cfDNA mutations went on to receive matched therapy compared with 7 of 19 (36.8%) patients with actionable TG results. Matched therapies included SERDs, inhibitors of CDK 4/6, PI3K, mTOR, HER2 directed therapy, and DNA damaging chemotherapy. The impact of matched therapy on survival outcomes will be presented at the meeting.

Conclusions: In patients undergoing both TG and cfDNA testing, both tests identify a significant cohort of HR+ MBC patients with actionable mutations, with greater detection of actionable mutations by cfDNA. Greater application of matched therapy occurred via cfDNA, which independently informed the selection of matched therapies. Further research is needed to prospectively evaluate the clinical utility of blood based genotyping assays versus TG for patients with MBC.

Citation Format: Vidula N, Juric D, Niemierko A, Spring L, Moy B, Malvarosa G, Yuen M, Habin K, Shin J, Peppercorn J, Isakoff S, Ellisen L, Iafrate AJ, Bardia A. Comparison of tumor genotyping and cell-free circulating tumor DNA sequencing in metastatic breast cancer patients and their utility in the selection of matched therapy [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 P4-01-06.

Postglacial history of a widespread conifer produces inverse clines in selective neutrality tests

Deviations of the site frequency spectrum of mutations (SFS) from neutral expectations may be caused by natural selection or by demographic processes such as population subdivision or temporal changes in population size. As most widespread temperate and boreal tree species have expanded from glacial refugia in the past 13,000 years, colonization bottlenecks associated with this migration may have left variable demographic signatures among geographic populations corresponding to distance from the refugia. To determine whether the signature of postglacial re-colonization has skewed the SFS in the widely distributed conifer Sitka spruce (Picea sitchensis (Bong.) Carr.), we re-sequenced 153 nuclear genes in six populations from across the species range. We found that while the SFS for the pooled sample produced negative values for Tajima's D and Fay and Wu's H, these statistics exhibited strong clinal variation when populations were analysed separately (R(2) = 0.84, P = 0.007 for Tajima's D and R(2)  = 0.65, P = 0.033 for Fay and Wu's H). When historical bottlenecks of varying age were simulated using approximate Bayesian computation, distance of populations from the southern range limit explained most of the variation in bottleneck timing among populations (R(2) = 0.89, P = 0.003). These data suggest that sequential population bottlenecks during postglacial re-colonization have resulted in diverse among-population signatures within the contemporary SFS in Sitka spruce, with rare variants more common in the south, and medium-frequency variants more common in the north. Our results also emphasize the need to consider sampling strategy and to explore population-specific null demographic models in surveys of nucleotide variation in widely distributed species.

Atmospheric mercury speciation in Yellowstone National Park

Atmospheric concentrations of elemental mercury (Hg(0)), reactive gaseous Hg (RGM), and particulate Hg (pHg) concentrations were measured in Yellowstone National Park (YNP), U.S.A. using high resolution, real time atmospheric mercury analyzers (Tekran 2537A, 1130, and 1135). A survey of Hg(0) concentrations at various locations within YNP showed that concentrations generally reflect global background concentrations of 1.5-2.0 ng m(-3), but a few specific locations associated with concentrated geothermal activity showed distinctly elevated Hg(0) concentrations (about 9.0 ng m(-3)). At the site of intensive study located centrally in YNP (Canyon Village), Hg(0) concentrations did not exceed 2.5 ng m(-3); concentrations of RGM were generally below detection limits of 0.88 pg m(-3) and never exceeded 5 pg m(-3). Concentrations of pHg ranged from below detection limits to close to 30 pg m(-3). RGM and pHg concentrations were not correlated with any criteria gases (SO(2), NO(x), O(3)); however pHg was weakly correlated with the concentration of atmospheric particles. We investigated three likely sources of Hg at the intensive monitoring site: numerous geothermal features scattered throughout YNP, re-suspended soils, and wildfires near or in YNP. We examined relationships between the chemical properties of aerosols (as measured using real time, single particle mass spectrometry; aerosol time-of-flight mass spectrometer; ATOFMS) and concentrations of atmospheric pHg. Based on the presence of particles with distinct chemical signatures of the wildfires, and the absence of signatures associated with the other sources, we concluded that wildfires in the park were the main source of aerosols and associated pHg to our sampling site.

Helicobacter westmeadii sp. nov., a new species isolated from blood cultures of two AIDS patients

A slowly growing anaerobic Helicobacter species was isolated from the blood cultures of two human immunodeficiency virus-positive patients admitted to Westmead Hospital, Westmead, Australia, with fevers. The morphology of the isolates was consistent with Helicobacter cinaedi or Helicobacter fennelliae. The results of culture growth conditions, biochemical tests, gas chromatography data, ribotyping, and 16S rDNA sequencing showed that these isolates represent a new Helicobacter species, for which the name Helicobacter westmeadii has been proposed.

Absence of retroviral antibodies in the sera of patients with systemic lupus erythematosus

Retroviruses have been postulated as environmental triggers in the aetiopathogenesis of systemic lupus erythematosus. Sera from 100 lupus patients were screened for the presence of antibodies against recombinant HIV-1 core and envelope, and HIV-2 envelope antigens by an enzyme immunoassay. This will detect antibodies resulting from direct HIV-1 or HIV-2 infections or those generated as a result of antigenic similarities by other human retroviruses. The sera were obtained from 11 male and 89 female lupus patients. Retroviral antibodies were not detected in the sera of these lupus patients, thus contradicting published findings that up to 30% of lupus patients have antibodies against the p24 gag protein of HIV-1.

Serological cross-reaction between Legionella spp. and Capnocytophaga ochracea by using latex agglutination test

Cross-reactivity between Legionella spp. and Capnocytophaga ochracea was noted by latex agglutination tests (Serobact Legionella; Disposable Products, Adelaide, Australia). Four of 11 (36%) C. ochracea isolates agglutinated with latex reagents designed to identify Legionella pneumophila serogroups. C. ochracea isolated on buffered charcoal yeast extract media may give false-positive results in this Legionella latex agglutination assay.

Focal fibrocartilaginous dysplasia and tibia vara: a case report

A 2-year-old black boy with focal fibrocartilaginous dysplasia is described with illustrations of the typical radiographic appearances supplemented by computed tomographic and magnetic resonance images. Since this rare condition is self-correcting, diagnosis is important so that surgical intervention and biopsy can be avoided and conservative management instituted.

Influence of lactoferrin on iron absorption from human milk in infants

Lactoferrin (Lf) is a major iron (Fe)-binding protein in human milk and has been proposed to facilitate Fe absorption. The potential effect of Lf on Fe absorption was investigated by measuring Fe absorption in infants fed breast milk (with its native content of Lf) and the same milk from which Lf had been removed (> 97%) by treatment with heparin-Sepharose. Eight breast-fed infants (2-10 mo; mean age 5 mo) were fed 700 to 1000 g of each milk in a randomized, cross-over design with each child acting as his/her own control. The milk was labeled with 8.6 mumol (0.5 mg) of 58Fe and Fe absorption was measured by quantifying the incorporation of the isotope into red blood cells 14 d after intake using thermal ionization mass spectrometry. Fractional Fe absorption was significantly lower (p < 0.05) from breast milk than from Lf-free breast milk. The geometric mean (range) was 11.8% (3.4-37.4%) for breast milk and 19.8% (8.4-72.8%) for Lf-free breast milk. These results do not support a direct role for Lf in the enhancement of Fe absorption from human milk at this age. In addition, Fe absorption (11.8%) from human milk fed over several feeds was lower than that previously reported for single feed studies.

Magnesium bioavailability from human milk, cow milk, and infant formula in suckling rat pups

Little is known about the absorption of magnesium from infant diets. Magnesium bioavailability was evaluated from infant diets that varied by protein and carbohydrate source; magnesium, calcium, and phosphorus contents; and the form of magnesium fortification. Diets were separated into soluble, insoluble, and fat fractions to determine magnesium distribution. Most of the magnesium (> 62%) was found in the soluble fraction. Gel filtration of the soluble fraction from all diets studied showed that > 95% of magnesium is free or associated with low-molecular-weight compounds. Distribution of 28Mg and native magnesium in fractions of the diets was similar, thus validating the use of an extrinsic label. In vitro digestion decreased the percent insoluble magnesium from as high as 35% to 2-8%. Whole-body retention of 28Mg-labeled diets in suckling rat pups 4 h after oral intubation ranged from 51% to 92%. No significant differences were found between human milk, cow milk, and infant formula. In conclusion, magnesium from the infant diets studied has high bioavailability, and moderate differences in their composition do not affect bioavailability significantly.

Proliferative periosteal processes of phalanges: a unitary hypothesis

A unitary hypothesis is offered to explain the various proliferative processes occurring around the phalanges. In the past, these have been separately designated as proliferative periostitis, bizarre parosteal osteochondromatous proliferation, and turret exostosis. Because the appearances of these entities depend on temporal factors, breaching of the periosteum, and local anatomic features, we suggest a single term, proliferative periosteal processes of phalanges.

Diagnosis of classical Morquio's disease: N-acetylgalactosamine 6-sulphate sulphatase activity in cultured fibroblasts, leukocytes, amniotic cells and chorionic villi

The tritiated disulphated trisaccharide 6-sulpho-N-acetylgalactosamine-glucuronic acid-6-sulpho-N-acetyl-[1-3H]galactosaminitol was prepared from chondroitin 6-sulphate for use as a substrate for N-acetylgalactosamine 6-sulphate sulphatase. The reaction product was separated on ECTEOLA cellulose rather than Dowex 1 X 2. The mean activities of normal fibroblasts, leukocytes and amniotic cells were 8.43, 2.59 and 3.14 nmol h-1 mg protein-1, respectively. Fibroblasts from five patients with classical Morquio's disease (mucopolysaccharidosis IVA; MPSIVA) and one patient with neonatal multiple sulphatase deficiency displayed activities of less than 5% of control mean. Activity in amniotic cells from a pregnancy where the fetus was affected with MPS IVA was 6% of control mean. Activity was also found to be present in normal specimens of chorionic villi (mean value 1.21 nmol h-1 mg protein-1), demonstrating the feasibility of first trimester prenatal diagnosis of MPS IVA by assay of activity in this tissue.