Theory of mind in neurodevelopmental disorders: beyond autistic spectrum disorder

INTRODUCTION

Theory of mind (ToM) is the human ability to perceive, interpret, and attribute the mental states of other people, and the alteration of this cognitive function is a core symptom of autistic spectrum disorder (ASD). In such other neurodevelopmental disorders as childhood-onset obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) that can present with cognitive dysfunctions, ToM has been less extensively studied, especially in the young population. The aim of the study was to compare advanced ToM between groups of young people diagnosed with OCD, TS, or ASD and a control group.

METHODS

Clinical interviews were conducted with male patients aged between 11 and 17 years with a main diagnosis of OCD (n = 19), TS (n = 14), or ASD (n = 18), and a control group (n = 20). We administered instruments for estimating intelligence quotient and severity of psychiatric symptoms, and tasks to evaluate ToM (the "Stories from everyday life" task and the "Reading the mind in the eyes" test).

RESULTS

Young people with TS and with ASD present similar difficulties in solving advanced ToM tasks, whereas patients with childhood-onset OCD present similar results to controls.

CONCLUSIONS

ToM is altered in other neurodevelopmental disorders beyond ASD, such as TS.

Pathology Residents' Perceptions and Attitudes Toward Breast Pathology: A National Survey

CONTEXT.—

Breast pathology (BP) is considered to be subject to interobserver variability among pathologists, emphasizing the need for adequate training. However, specifics of BP residency training have not been elucidated.

OBJECTIVE.—

To assess the characteristics of BP residency training in the United States.

DESIGN.—

A Qualtrics-managed online survey was emailed to program directors of all US pathology residency programs, requesting them to forward the survey link to their pathology residents.

RESULTS.—

One hundred seventeen residents' survey responses were evaluable. Most responses (92; 79%) came from residents in university hospital-based programs. Thirty-five respondents (30%) had a dedicated BP rotation in their program. Most respondents believed that BP was an important part of training (96 of 100; 96%) and pathology practice (95 of 100; 95%). Seventy-one respondents believed that their BP training was adequate overall (71 of 100; 71%). Forty-one percent of respondents indicated that they would not like BP to be a significant part of their future practice. The main reasons given were that they had a different preferred area of interest, that they lacked interest in BP, or that breast cases were time-consuming to sign out.

CONCLUSIONS.—

Our results show that in the United States, most programs do not offer a dedicated BP rotation, but breast cases are signed out by subspecialized or experienced breast pathologists. In addition, most respondents believed that they received adequate training and would be competent to independently sign out BP in the future. Additional studies addressing new-in-practice pathologists' proficiency in BP will further help elucidate the quality of BP training in the United States.

Abstract OT3-19-01: Phase II Study of Screening Brain MRIs in Stage IV Breast Cancer

Background: As systemic therapy improves, there has been an increasing number of breast cancer patients who develop brain metastasis. Screening of asymptomatic stage IV breast cancer patients with brain MRIs is not currently recommended by the National Comprehensive Cancer Network (NCCN) Guidelines. Retrospective reports suggest breast cancer patients are more likely to present with more advanced central nervous system disease at the time of brain metastasis diagnosis compared to melanoma and non-small cell lung cancer (NSCLC) patients. This may be in part due to routine screening recommendations in melanoma and NSCLC. Early detection and treatment of brain metastases may improve outcomes for breast cancer patients. Trial Design: The study is designed as a single arm, nonrandomized phase II study, with the goal of investigating the role of screening brain MRIs in neurologically asymptomatic patients with metastatic breast cancer. Breast cancer patients will be allocated based on receptor subtypes into triple negative (TN), HER2+, and hormone receptor (HR)+/HER2- breast cancer. Following study enrollment, patients will undergo a screening brain MRI. Patients will undergo a second brain MRI at first systemic progression or at 6 months whichever event occurs sooner. Eligibility: Asymptomatic, stage IV breast cancer patients that have progressed past first line therapy in the metastatic setting with an ECOG/= 6 months are eligible. Specific Aims: The primary objective is to determine the incidence of asymptomatic brain metastasis in metastatic breast cancer by subtype. Secondary objectives include determining the incidence of asymptomatic leptomeningeal disease, the number and size of brain metastases at diagnosis, the number of patients requiring whole brain radiation therapy vs. stereotactic radiation following diagnosis and overall survival and brain metastasis specific survival following brain metastasis diagnosis in metastatic breast cancer by subtype. Statistical Methods: A total of 30, 30, and 40 TN, HER2+, and HR+/HER2-, breast cancer patients will be enrolled, respectively. Using an incidence rate of 17%, the 95% CI by subtype will be (0.06,0.351), (0.06,0.351), and (0.07,0.322). Patient Accrual: This study is open with 30 patients enrolled at the time of submission. A total of 100 patients will be enrolled. Contact Information: Kamran A. Ahmed MD, Moffitt Cancer Center, email: kamran.ahmed@moffitt.org, Clinical trial information: NCT05115474. Funding: Florida Breast Cancer Foundation.

Citation Format: Kamran A. Ahmed, Youngchul Kim, Avan Armaghani, John Arrington, Ricardo Costa, Brian J. Czerniecki, Roberto Diaz, Peter A. Forsyth, Hung Khong, Kimberley Lee, Loretta Loftus, Marilin Rosa, Hatem H. Soliman, Iman Washington, Aixa Soyano, Hyo S. Han. Phase II Study of Screening Brain MRIs in Stage IV 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 OT3-19-01.

Clinicopathologic Predictors of Clinical Outcomes in Mammary Adenoid Cystic Carcinoma: A Multi-institutional Study

Adenoid cystic carcinoma (AdCC) is an uncommon type of invasive breast carcinoma with a favorable prognosis. However, some cases are aggressive. The study aims to define the clinicopathologic predictors of outcome. Clinical, radiological, and pathologic variables were recorded for 76 AdCC cases from 11 institutions. The following histologic characteristics were evaluated by the breast pathologist in each respective institution, including Nottingham grade (NG), percentages of various growth patterns (solid, cribriform, trabecular-tubular), percentage of basaloid component, tumor borders (pushing, infiltrative), perineural invasion, lymphovascular invasion, necrosis, and distance from the closest margin. Various grading systems were evaluated, including NG, salivary gland-type grading systems, and a new proposed grading system. The new grading system incorporated the growth pattern (percent solid, percent cribriform), percent basaloid morphology, and mitotic count using the Youden index criterion. All variables were correlated with recurrence-free survival. Nineteen (25%) women developed local and/or distant recurrence. Basaloid morphology (≥25% of the tumor) was identified in 20 (26.3%) cases and a solid growth pattern (using ≥60% cutoff) in 22 (28.9%) cases. In the univariate analysis, the following variables were significantly correlated with worse recurrence-free survival: solid growth pattern, basaloid morphology, lymphovascular invasion, necrosis, perineural invasion, and pN-stage. In the multivariate analysis including basaloid morphology, pN-stage, lymphovascular invasion, and perineural invasion, basaloid morphology was statistically significant, with a hazard ratio of 3.872 (95% CI, 1.077; 13.924; P =.038). The NG and the new grading system both correlated with recurrence-free survival. However, grade 2 had a similar risk as grade 3 in the NG system and a similar risk as grade 1 in the new grading system. For solid growth patterns and basaloid morphology, using a 2-tier system with 1 cutoff was better than a 3-tier system with 2 cutoffs. Basaloid morphology and solid growth pattern have prognostic values for AdCC, with a 2-tier grading system performing better than a 3-tier system.

Oncolytic T-VEC virotherapy plus neoadjuvant chemotherapy in nonmetastatic triple-negative breast cancer: a phase 2 trial

Talimogene laherparepvec (T-VEC) is an oncolytic virus hypothesized to enhance triple-negative breast cancer (TNBC) responses to neoadjuvant chemotherapy (NAC). This article describes the phase 2 trial of T-VEC plus NAC (ClinicalTrials.gov ID: NCT02779855 ). Patients with stage 2-3 TNBC received five intratumoral T-VEC injections with paclitaxel followed by doxorubicin and cyclophosphamide and surgery to assess residual cancer burden index (RCB). The primary end point was RCB0 rate. Secondary end points were RCB0-1 rate, recurrence rate, toxicity and immune correlates. Thirty-seven patients were evaluated. Common T-VEC toxicities were fevers, chills, headache, fatigue and injection site pain. NAC toxicities were as expected. Four thromboembolic events occurred. The primary end point was met with an estimated RCB0 rate = 45.9% and RCB0-1 descriptive rate = 65%. The 2-year disease-free rate is equal to 89% with no recurrences in RCB0-1 patients. Immune activation during treatment correlated with response. T-VEC plus NAC in TNBC may increase RCB0-1 rates. These results support continued investigation of T-VEC plus NAC for TNBC.

Ethnic and racial-specific differences in levels of centrosome-associated mitotic kinases, proliferative and epithelial-to-mesenchymal markers in breast cancers

Molecular epidemiology evidence indicates racial and ethnic differences in the aggressiveness and survival of breast cancer. Hispanics/Latinas (H/Ls) and non-Hispanic Black women (NHB) are at higher risk of breast cancer (BC)-related death relative to non-Hispanic white (NHW) women in part because they are diagnosed with hormone receptor-negative (HR) subtype and at higher stages. Since the cell cycle is one of the most commonly deregulated cellular processes in cancer, we propose that the mitotic kinases TTK (or Mps1), TBK1, and Nek2 could be novel targets to prevent breast cancer progression among NHBs and H/Ls. In this study, we calculated levels of TTK, p-TBK1, epithelial (E-cadherin), mesenchymal (Vimentin), and proliferation (Ki67) markers through immunohistochemical (IHC) staining of breast cancer tissue microarrays (TMAs) that includes samples from 6 regions in the Southeast of the United States and Puerto Rico -regions enriched with NHB and H/L breast cancer patients. IHC analysis showed that TTK, Ki67, and Vimentin were significantly expressed in triple-negative (TNBC) tumors relative to other subtypes, while E-cadherin showed decreased expression. TTK correlated with all of the clinical variables but p-TBK1 did not correlate with any of them. TCGA analysis revealed that the mRNA levels of multiple mitotic kinases, including TTK, Nek2, Plk1, Bub1, and Aurora kinases A and B, and transcription factors that are known to control the expression of these kinases (e.g. FoxM1 and E2F1-3) were upregulated in NHBs versus NHWs and correlated with higher aneuploidy indexes in NHB, suggesting that these mitotic kinases may be future novel targets for breast cancer treatment in NHB women.

Association of Residual Ductal Carcinoma In Situ With Breast Cancer Recurrence in the Neoadjuvant I-SPY2 Trial

Importance

Pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer strongly correlates with overall survival and has become the standard end point in neoadjuvant trials. However, there is controversy regarding whether the definition of pCR should exclude or permit the presence of residual ductal carcinoma in situ (DCIS).

Objective

To examine the association of residual DCIS in surgical specimens after neoadjuvant chemotherapy for breast cancer with survival end points to inform standards for the assessment of pathologic complete response.

Design, Setting, and Participants

The study team analyzed the association of residual DCIS after NAC with 3-year event-free survival (EFS), distant recurrence-free survival (DRFS), and local-regional recurrence (LRR) in the I-SPY2 trial, an adaptive neoadjuvant platform trial for patients with breast cancer at high risk of recurrence. This is a retrospective analysis of clinical specimens and data from the ongoing I-SPY2 adaptive platform trial of novel therapeutics on a background of standard of care for early breast cancer. I-SPY2 participants are adult women diagnosed with stage II/III breast cancer at high risk of recurrence.

Interventions

Participants were randomized to receive taxane and anthracycline-based neoadjuvant therapy with or without 1 of 10 investigational agents, followed by definitive surgery.

Main Outcomes and Measures

The presence of DCIS and EFS, DRFS, and LRR.

Results

The study team identified 933 I-SPY2 participants (aged 24 to 77 years) with complete pathology and follow-up data. Median follow-up time was 3.9 years; 337 participants (36%) had no residual invasive disease (residual cancer burden 0, or pCR). Of the 337 participants with pCR, 70 (21%) had residual DCIS, which varied significantly by tumor-receptor subtype; residual DCIS was present in 8.5% of triple negative tumors, 15.6% of hormone-receptor positive tumors, and 36.6% of ERBB2-positive tumors. Among those participants with pCR, there was no significant difference in EFS, DRFS, or LRR based on presence or absence of residual DCIS.

Conclusions and Relevance

The analysis supports the definition of pCR as the absence of invasive disease after NAC regardless of the presence or absence of DCIS.

Trial Registration

ClinicalTrials.gov Identifier NCT01042379.

Quantitative Changes in Intratumoral Habitats on MRI Correlate With Pathologic Response in Early-stage ER/PR+ HER2- Breast Cancer Treated With Preoperative Stereotactic Ablative Body Radiotherapy

Objective

To quantitatively evaluate intratumoral habitats on dynamic contrast-enhanced (DCE) breast MRI to predict pathologic breast cancer response to stereotactic ablative body radiotherapy (SABR).

Methods

Participants underwent SABR treatment (28.5 Gy x3), baseline and post-SABR MRI, and breast-conserving surgery for ER/PR+ HER2- breast cancer. MRI analysis was performed on DCE T1-weighted images. MRI voxels were assigned eight habitats based on high (H) or low (L) maximum enhancement and the sequentially numbered dynamic sequence of maximum enhancement (H1-4, L1-4). MRI response was analyzed by percent tumor volume remaining (%VR = volume post-SABR/volume pre-SABR), and percent habitat makeup (%HM of habitat X = habitat X voxels/total voxels in the segmented volume). These were correlated with percent tumor bed cellularity (%TC) for pathologic response.

Results

Sixteen patients completed the trial. The %TC ranged 20%-80%. MRI %VR demonstrated strong correlations with %TC (Pearson R = 0.7-0.89). Pre-SABR tumor %HMs differed significantly from whole breasts (P = 0.005 to <0.00001). Post-SABR %HM of tumor habitat H4 demonstrated the largest change, increasing 13% (P = 0.039). Conversely, combined %HM for H1-3 decreased 17% (P = 0.006). This change correlated with %TC (P < 0.00001) and distinguished pathologic partial responders (≤70 %TC) from nonresponders with 94% accuracy, 93% sensitivity, 100% specificity, 100% positive predictive value, and 67% negative predictive value.

Conclusion

In patients undergoing preoperative SABR treatment for ER/PR+ HER2- breast cancer, quantitative MRI habitat analysis of %VR and %HM change correlates with pathologic response.

Abstract P2-14-01: Phase II neoadjuvant trial of Interferon-gamma plus weekly paclitaxel, trastuzumab and pertuzumab in patients with HER-2 positive breast cancer

Background: IFN-γ, a cytokine that plays diverse roles in innate and adaptive immunity, has been shown to be essential in anti-tumor immune response. In vitro and in vivo studies have shown the synergistic effect of IFN-γ in combination with HER2-targeting monoclonal antibodies with or without taxane chemotherapy. We previously conducted a phase I trial of IFN-γ in combination with paclitaxel, trastuzumab and pertuzumab (IPTP) in metastatic HER2-positive breast cancer (HER2+ BC) based on which we initiated a phase II neoadjuvant study with this combination. Methods: Early stage HER2+ BC patients (pts) were eligible. Treatment included 12 weeks of weekly paclitaxel 80 mg/m2 IV, trastuzumab IV every 3 weeks x 4 (8 mg/kg loading dose, then 6 mg/kg) and pertuzumab IV every 3 weeks x 4 (840 mg loading dose, then 420 mg) in combination with IFN-γ 50 mcg/m2 subcutaneous injection three times weekly starting on day 1. The primary objective was to evaluate the pathologic complete response rate (pCR) in breast and nodes. This study had a planned interim analysis after 23 patients were evaluable for pCR based on a Simon’s two stage design with 90% power and a type I error rate of 0.1. The final proportion of hormone receptor (HR) status among accrued patients will be used for comparison to historical control because pCR is expected to be lower for HR+HER2+BC compared to HR-HER2+ BC subtype (25% vs 50% respectively). Here we are reporting the final results. Results: Thirty-nine pts were enrolled between 1/2018 and 11/2020. Most patients had clinical stage II/III (90%) and 46% were clinically and pathologically node positive. Thirty four out of 39 (87%) had HR+ BC. The pCR for all patients was 44% (17/39). The pCR for HR+ HER2+ and HR-HER2+ BC subgroup was 47% (16/34) and 20% (1/5) respectively. Further evaluation using RCB (residual cancer burden) showed 17 pts RCB-0, 6 RCB-I,14 RCB-II, and 2 RCB-III. Two SAE included pneumonitis/heart failure and hematochezia. The most frequently observed grade 1 and 2 AEs were diarrhea (74%), fatigue (74%), rash (56%) and nausea (56%). Grade 3 AE (5% or higher) included diarrhea (18%), syncope (5%) and rash (5%). No grade 4 AE was noted. Conclusion: The addition of IFN-γ to neoadjuvant chemotherapy using paclitaxel, trastuzumab and pertuzumab was well tolerated with manageable toxicities. This study evaluated de-escalated treatments only 12 weeks duration and the anthracycline-free regimen which was highly effective with pCR of 44%. The pCR for HR+ HER2 + BC subtype was 47% (16/34) which compares favorably to the expected pCR of 25% with neoadjuvant chemotherapy alone in HR+HER2+ patients. Updated results will be presented at the meeting including correlative studies.

Citation Format: Hyo S Han, Ricardo Costa, Avan Armaghani, Aixa Soyano, Loretta Loftus, Hatem Soliman, Brooke Fridley, Junmin Whiting, Aiana Cerezo, Marilin Rosa, Martine Extermann, Hung Khong, Brian Czerniecki. Phase II neoadjuvant trial of Interferon-gamma plus weekly paclitaxel, trastuzumab and pertuzumab in patients with HER-2 positive breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-14-01.

Abstract OT2-09-01: Phase I/II study of stereotactic radiation and abemaciclib in the management of hormone receptor positive HER2 negative breast cancer brain metastases

Background: Breast cancer patients with brain metastases have a high unmet clinical need and improved management strategies are needed. There has been interest in studying CDK 4/6 inhibitors in the management of breast cancer brain metastases. A phase II study has shown abemaciclib to have activity in the management of hormone receptor (HR)+/HER2- brain metastases. Pre-clinical data suggests a potential synergy with CDK inhibitors and radiation therapy. Stereotactic radiosurgery (SRS) is a cornerstone in the management of limited brain metastases. We hypothesize treatment with abemaciclib and SRS will be safe and improve intracranial progression free survival (PFS) compared to abemaciclib alone. Trial Design: The study is designed as a prospective, single-arm, nonrandomized, open-label, phase I/II trial of abemaciclib and endocrine therapy with SRS among patients with HR+/HER2- metastatic breast cancer brain metastases. Treatment will be initiated with one week of abemaciclib followed by stereotactic radiation to sites of brain metastases or post-operative cavities with continued abemaciclib. Safety will be monitored initially by a 3+3 design. If unexpected neurologic toxicities are noted, the dose of radiation therapy will be reduced. This will be followed by a phase II study to evaluate intracranial PFS. Eligibility: Eligible patients include those that are HR+/HER2-, ≥18, ECOG ≤2 with ≤15 breast cancer brain metastases with measurable disease per Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) criteria. Specific Aims: The primary objective of the phase I study is to evaluate the safety and feasibility of abemaciclib and SRS to sites of brain metastases in the management of HR+/HER2- metastatic breast cancer with brain metastases. The primary objective of the phase II portion is to determine PFS intracranially. Secondary objectives include evaluation of extracranial PFS, local and distant intracranial control, and overall survival. Statistical Methods: Safety and feasibility will be monitored in the phase I study using a 3 + 3 design followed by a phase II study to assess intracranial PFS. The phase II study is designed as a single-arm, two-stage trial using the Restricted-Kwak-and-Jung’s method. In the first stage, a total of 21 patients will be enrolled. If pre-specified endpoints are met, an additional 10 patients will be enrolled in the second stage. Patient Accrual: A total of up to 31 patients will be enrolled inclusive of patients in the phase I portion treated at the recommended phase II dose. Clinical trial information: NCT04923542.

Citation Format: Kamran A. Ahmed, Youngchul Kim, Michelle DeJesus, Sasha J. Beyer, Nicole O. Williams, Joshua Palmer, Kristina D. Woodhouse, Rashmi K. Murthy, Jing Li, Avan J. Armaghani, John A. Arrington, Ricardo L. Costa, Brian J. Czerniecki, Arnold B. Etame, Peter A. Forsyth, Hung T. Khong, Daniel E. Oliver, Marilin Rosa, Solmaz Sahebjam, Hatem H. Soliman, Aixa E. Soyano, Michael A. Vogelbaum, Michael Yu, Hyo S. Han. Phase I/II study of stereotactic radiation and abemaciclib in the management of hormone receptor positive HER2 negative breast cancer brain metastases [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT2-09-01.

Malignant Adenomyoepithelioma of the Breast and Associated Epithelial-Myoepithelial Carcinoma; A Rare Case Report

Adenomyoepithelioma comprises a spectrum of lesions with variable morphology and clinical behavior, presenting at a wide age range. The most common presenting symptom is palpable abnormality. Mammographic abnormalities include focal asymmetries, masses and microcalcifications. Adenomyoepithelioma is a biphasic neoplasm characterized by proliferation of epithelial and myoepithelial cells. Adenomyoepitheliomas can be benign, atypical and malignant (adenomyoepithelioma with carcinoma). Malignant transformation occurs in either one or both cellular components leading to the development of invasive carcinoma. Invasive carcinoma types include invasive breast carcinoma of no special type, invasive lobular carcinoma, invasive carcinoma of special types, myoepithelial carcinoma, metaplastic carcinoma and biphasic carcinoma such as epithelial-myoepithelial carcinoma. While the majority of classic adenomyoepitheliomas have a benign clinical course and can be treated by local excision, local recurrence and distant metastasis have been reported. In malignant cases, treatment is determined by the associated carcinoma to include radiotherapy after breast conserving surgery and sentinel lymph node biopsy or axillary lymph node dissection, as indicated. Herein we report a case of a 62 year old woman who was found to have focal asymmetry on screening mammogram. She underwent a core biopsy of the lesion which showed atypical epithelial-myoepithelial neoplasm and excision was recommended. Upon excision, a diagnosis of malignant adenomyoepithelioma with associated epithelial-myoepithelial carcinoma was rendered with negative margins. The patient declined additional surgery for sentinel lymph node biopsy and declined adjuvant therapy. Six months after surgery, the patient is doing well with no complains. A follow-up mammogram and ultrasound of the axilla showed no abnormalities.

Unique ER PR expression pattern in breast cancers with CHEK2 mutation: a hormone receptor and HER2 analysis based on germline cancer predisposition genes

Purpose

Estrogen-receptor (ER) and progesterone-receptor (PR) expression levels in breast cancer, which have been principally compared via binomial descriptors, can vary widely across tumors. We sought to characterize ER and PR expression levels using semi-quantitative analyses of receptor staining in germline pathogenic variant (PV) carriers of cancer predisposition genes.

Methods

We conducted a retrospective chart review of patients who underwent germline genetic testing for cancer predisposition genes at a tertiary cancer center genetics clinic. We performed comparisons of semi-quantitative ER and PR percentage staining levels across carriers and non-carriers of cancer predisposition genes.

Results

Breast cancers from BRCA1 PV carriers expressed significantly lower ER (15.2% vs 78.2%, p < 0.001) and lower PR (6.8% vs 41.1%, p < 0.001) staining compared to non-PV carriers. Similarly, breast cancers of BRCA2 (66.7% vs 78.2%, p = 0.005) and TP53 (50.6% vs 78.2%, p = 0.015) PV tumors also displayed moderate decreases in ER staining. Conversely, CHEK2 tumors displayed higher ER (93.1% vs 78.2%, p = 0.005) and PR (72% vs 48.8%, p = 0.001) staining when compared to non-PV carriers. We observed a wide range of dispersion across the ER and PR staining levels of the carriers and noncarriers. ER and PR ranges of dispersion of CHEK2 tumors were uniquely narrower than all other groups.

Conclusion

The findings of our study suggest that precise expression levels of ER and PR in breast cancers can vary widely. These differences are further augmented when comparing expression staining across PV and non-PV carriers, suggesting potentially unique tumorigenesis and progression pathways influenced by germline cancer predisposition genes.

Nivolumab and Stereotactic Radiosurgery for Patients With Breast Cancer Brain Metastases: A Nonrandomized, Open-Label Phase 1b Study

Purpose

Methods and Materials

Results

Conclusions

MRI Response to Pre-operative Stereotactic Ablative Body Radiotherapy (SABR) in Early Stage ER/PR+ HER2- Breast Cancer correlates with Surgical Pathology Tumor Bed Cellularity

OBJECTIVE

This study evaluates breast MRI response of ER/PR+ HER2- breast tumors to pre-operative SABR with pathologic response correlation.

METHODS

Women enrolled in a phase 2 single institution trial of SABR for ER/PR+ HER2- breast cancer were retrospectively evaluated for radiologic-pathologic correlation of tumor response. These patients underwent baseline breast MRI, SABR (28.5 Gy in 3 fractions), follow-up MRI 5 to 6 weeks post-SABR, and lumpectomy. Tumor size and BI-RADS descriptors on pre and post-SABR breast MRIs were compared to determine correlation with surgical specimen % tumor cellularity (%TC). Reported MRI tumor dimensions were used to calculate percent cubic volume remaining (%VR). Partial MRI response was defined as a BI-RADs descriptor change or %VR ≤ 70%, while partial pathologic response (pPR) was defined as %TC ≤ 70%.

RESULTS

Nineteen patients completed the trial, and %TC ranged 10% to 80%. For BI-RADS descriptor analysis, 12 of 19 (63%) showed change in lesion or kinetic enhancement descriptors post-SABR. This was associated with lower %TC (29% vs. 47%, P = .042). BI-RADS descriptor change analysis also demonstrated high PPV (100%) and specificity (100%) for predicting pPR to treatment (sensitivity 71%, accuracy 74%), but low NPV (29%). MRI %VR demonstrated strong linear correlation with %TC (R = 0.70, P < .001, Pearson's Correlation) and high accuracy (89%) for predicting pPR (sensitivity 88%, specificity 100%, PPV 100%, and NPV 50%).

CONCLUSION

Evaluating breast cancer response on MRI using %VR after pre-operative SABR treatment can help identify patients benefiting the most from neoadjuvant radiation treatment of their ER/PR+ HER2- tumors, a group in which pCR to neoadjuvant therapy is rare.

Theory of mind in neurodevelopmental disorders: Beyond autistic spectrum disorder

INTRODUCTION

Theory of mind (ToM) is the human ability to perceive, interpret, and attribute the mental states of other people, and the alteration of this cognitive function is a core symptom of autistic spectrum disorder (ASD). In such other neurodevelopmental disorders as childhood-onset obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) that can present with cognitive dysfunctions, ToM has been less extensively studied, especially in the young population. The aim of the study was to compare advanced ToM between groups of young people diagnosed with OCD, TS, or ASD and a control group.

METHODS

Clinical interviews were conducted with male patients aged between 11 and 17 years with a main diagnosis of OCD (n=19), TS (n=14), or ASD (n=18), and a control group (n=20). We administered instruments for estimating intelligence quotient and severity of psychiatric symptoms, and tasks to evaluate ToM (the "Stories from everyday life" task and the "Reading the mind in the eyes" test).

RESULTS

Young people with TS and with ASD present similar difficulties in solving advanced ToM tasks, whereas patients with childhood-onset OCD present similar results to controls.

CONCLUSIONS

ToM is altered in other neurodevelopmental disorders beyond ASD, such as TS.

Breast cancer ER, PR, and HER2 expression variance by germline cancer predisposition genes

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Background: The association between breast cancer characteristics and survival with estrogen receptor (ER) and progesterone receptor (PR) expression has been primarily studied via binomial categories, ER-positive and ER-negative. In order to better characterize germline genetic influences on these markers, we investigated their IHC expression semi-quantitatively in cancer predisposition germline pathogenic variant (PV) carriers of the following genes: BRCA1, BRCA2, PALB2, TP53, PTEN, CDH1, ATM, CHEK2, and Lynch syndrome genes. The HER2 expression was also analyzed. Methods: We conducted a retrospective chart review of patients with germline panel genetic testing for cancer predisposition genes at Moffitt Cancer Center’s GeneHome clinic. Inclusion criteria included 1) women ≥18 years old, 2) breast cancer diagnosis, 3) cancer predisposition germline panel genetic test results, 4) available ER and PR expression levels, and 5) available HER expression and/or amplification status. ER, PR, and HER2 status were compared between PV carriers and non-PV carriers via Mann-Whitney U at p>0.05. Results: A total of 847 cases were reviewed for the study. Among 658 patients with a breast cancer diagnosis and complete ER PR data, 365 cases (55.5%) were non-PV carriers and 293 cases (44.5%) carried a PV in at least one of the genes listed above. Among 635 cases with available HER2 expression/amplification status, 355 (55.9%) cases were non-PV carriers and 288 (45.4%) cases were PV-carriers. When compared with non-PV carrier controls, BRCA1 PV carriers’ breast tumors had significantly lower ER and/or PR expression. Further, BRCA2 and TP53 PV tumors also displayed moderately lower ER expression. Contrarily, CHEK2 tumors displayed higher ER and PR expression compared to controls. Further, BRCA1 and BRCA2 PV carriers were more likely to have HER2- breast cancers. Conclusions: Differences in ER, PR, HER2 expression levels were observed in germline PV carrier breast cancers, signaling differential impacts by germline PVs on the tumor evolution process. It is likely that tumor differences in PV carriers influence responses to therapies, including hormone therapy, anti-HER2 therapy, and subsequent survival.[Table: see text]

Nivolumab and stereotactic radiosurgery for patients with breast cancer brain metastases: A non-randomized, open-label phase Ib study

e14010

Background: There may be a potential synergy intracranially between stereotactic radiation and immune checkpoint inhibition in brain metastases management. We hypothesize treatment with nivolumab and stereotactic radiosurgery (SRS) will be feasible and well tolerated and may improve intracranial tumor control rates compared to SRS alone in the management of breast cancer brain metastases. Methods: The study was designed as a prospective, single-arm, nonrandomized, open-label, phase Ib trial of nivolumab and SRS among patients with metastatic breast cancer brain metastases. Key eligibility criteria included patients with breast cancer brain metastases of all subtypes, age ≥ 18, ECOG ≤ 2 with ≤ 10 brain metastases. The primary objective was to evaluate the safety and feasibility of study therapy. Secondary objectives included evaluation of local brain metastasis control, distant brain metastasis control, progression free survival (PFS), and overall survival following study therapy. Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) and immune-related Response Evaluation Criteria in Solid Tumors (irRECIST) criteria were used to assess intracranial and extracranial disease, respectively. Treatment was initiated with a dose of nivolumab (480 mg IV) that was repeated every 4 weeks. The initial dose of nivolumab was followed 1 week later by SRS. This study is closed to accrual and is registered with ClinicalTrials.gov, NCT03807765. Results: Between February 2019 and July 2020, a total of 12 patients were treated to 17 lesions. Median follow-up from start of protocol therapy is currently 9.6 months (range: 2.8-18.7 months). No dose limiting toxicities (DLTs) were noted in our patient population. The most common neurologic adverse events included grade 1-2 headaches and dizziness occurring in 5 (42%) of patients. Median intracranial control was 6.2 months (95% CI 3.0 -14) with 6 and 12 month control rates of 55% and 22%, respectively. A total of 4 patients had systemic progression during the study. Median time to systemic PFS has not been reached with 6 and 12 month rates of 63% and 51%, respectively. Conclusions: Nivolumab and SRS is a safe and feasible treatment option in breast cancer brain metastases. Preliminary studies reveal activity in certain breast cancer patients to study therapy. Clinical trial information: NCT03807765.

A phase 2 trial of talimogene laherparepvec (TVEC) in combination with neoadjuvant chemotherapy for the treatment of nonmetastatic triple-negative breast cancer

578

Background: TVEC is a modified oncolytic herpes simplex 1 (HSV1) virus currently FDA approved for the treatment of unresectable cutaneous and nodal melanoma. TVEC is designed to preferentially lyse tumor cells over normal tissue to release tumor associated antigens, produces GM-CSF to activate dendritic cells, and stimulates T cells to infiltrate the tumor (TILs). TILs in breast cancer are associated with better response to neoadjuvant chemotherapy (NAC), so we hypothesized that intratumoral TVEC may enhance response to NAC. We report results of a phase 2 trial combining NAC with TVEC in stage 2-3 TNBC. Methods: Stage II-III TNBC pts (N = 37) were to be enrolled into a single arm, optimal Simon 2 stage phase 2 trial with TVEC (10^6 PFU 1st dose then 10^8 PFU x 4 doses) weeks 1,4,6,8,10 + weekly paclitaxel (80mg/m2) IV x 12, followed by dose dense AC (doxorubicin/cyclophosphamide 60/600 mg/m2) IV q2weeks x 4 alone given preoperatively. Primary endpoint was residual cancer burden 0 rate (RCB0). Trial meets primary endpoint with ≥15 RCB0 responses out of 37 evaluable pts, assuming p1 = 45% vs. p0 = 30% with one sided type I error rate at 0.10 and power at 70%. Results: Forty pts were enrolled at Moffitt (5/2018 – 4/2020) and evaluable for safety with 3 pts non-evaluable for efficacy due to incomplete treatment. Study demographics: median age 49 (27-66), 67.5% White, 10% Black, 15% Hispanic, clinical stage II 83% and III 17%, node + 42%. The RCB0 rate = 16/37 (43%, 95% CI 27-61%) and additional 9 pts with RCB-1 (RCB0/1 rate 68%, 95% CI 50-82%). Toxicities did not differ significantly from expected NAC toxicities except for increased brief G1-2 fevers, chills, injection site pains. Four pts had G2-3 thromboembolic events (10%) slightly greater than expected 6% rate on NAC. Conclusions: Addition of TVEC to NAC increased RCB0 rates with manageable toxicities and warrants additional investigation in TNBC. Immune correlates and updated survival data will be presented at the meeting. Clinical trial information: NCT02779855.

Trial in progress: Phase I/II study of radiation therapy followed by intrathecal trastuzumab/pertuzumab in the management of HER2+ breast leptomeningeal disease

TPS1099

Background: HER2+ breast cancer patients with leptomeningeal disease (LMD) represent a poor prognosis population with a high unmet clinical need. Although a multitude of treatment options are available for the management of systemic disease, once metastases travel to the leptomeninges, patients have a lack of treatment options aside from traditional local approaches. Data from a phase I/II study reveals intrathecal (IT) trastuzumab to be well tolerated with improved overall survival (OS) compared to historical controls in HER2+ breast LMD. Radiotherapy can improve the flow of IT therapy through the cerebrospinal fluid (CSF) and provide symptomatic relief. The monoclonal antibody pertuzumab is used in conjunction with trastuzumab in the management of metastatic and localized HER2+ breast cancer. Given the role of radiotherapy in the management of LMD along with the role of pertuzumab in the management of HER2+ breast cancer, there is a strong clinical rationale to combine radiotherapy with IT trastuzumab/pertuzumab in the management of HER2+ breast LMD. Methods: The study is designed as a prospective, single-arm, nonrandomized, open-label, phase I/II trial of radiation therapy followed by IT trastuzumab/pertuzumab in the management of HER2+ breast LMD. HER2+ LMD patients identified by magnetic resonance imaging (MRI) and/or CSF cytology, ≥ 18, with a life expectancy > 8 weeks are eligible. Treatment is initiated with radiotherapy, whole brain radiotherapy and/or focal brain/spine radiation followed by IT trastuzumab/pertuzumab. Safety and feasibility will be monitored by a modified toxicity probability interval-2 (mTPI-2) design. Dose reductions of IT trastuzumab will not be allowed. Once the maximum tolerated dose of IT pertuzumab is determined, the phase II portion of the study will commence to determine OS. Secondary objectives involve defining the CSF pharmacokinetics of IT trastuzumab/pertuzumab, evaluating the response rate (leptomeningeal and parenchymal), and progression free survival (leptomeningeal and parenchymal) following IT trastuzumab/pertuzumab. In the phase 2 portion, a single-arm two-stage trial is designed using the Restricted-Kwak-and-Jung’s Method. The primary endpoint is one-year OS. An interim analysis will be performed after 20 patients are enrolled. This study is open with 1 patient enrolled at the time of submission. Clinical trial information: NCT04588545 .

Evaluation of tooth size in non-syndromic cleft lip and palate patients: A retrospective Italian study

AIM

This study aims to evaluate the dental dimension in cleft lip and palate patients presenting agenesis of at least an upper lateral incisor and to compare the results with those of two control groups. A control group consisted of general orthodontic patients without agenesis, while the other group consisted of orthodontic patients with agenesis of at least one upper lateral incisor.

METHODS

Records of 40 (30 male, 10 female) cleft lip and palate patients (Group A), 40 (17 male, 23 female) patients representing the control group of general orthodontic patients (Group B) and 40 patients (14 male, 26 female) with at least one missing lateral incisor (Group C) were collected and analysed. Mesiodistal tooth size of all teeth (except second and third molars) was measured on digital or plaster dental casts.

RESULTS

Tooth size in cleft lip and palate patients (Group A) was similar to that of the control group (Group B) of general orthodontic patients without tooth agenesis, except for the upper central incisors and the second upper left bicuspids that presented a significant reduction in the mesiodistal dental width. Non-syndromic patients with at least one missing upper lateral incisor showed a significant reduction of mesiodistal tooth size compared to Group A and to Group B.

CONCLUSION

Dental width of cleft lip and palate patients is similar to that of a normal orthodontic population, with the exception of the upper central incisor and upper premolars on one side.

Diffuse intrasinusoidal hepatic metastasis from breast cancer: Multimodality imaging with pathology correlation

Metastatic disease to the liver is a known and common site of breast cancer spread, classically presenting as either hypovascular or hypervascular masses. Rarely, hepatic metastatic disease may have an atypical diffuse and intrasinusoidal pattern of involvement, which may be radiographically occult or extremely challenging to diagnose even with multiphase contrast enhanced techniques. We report a case of a 28-year-old female with stage III invasive ductal carcinoma of the breast, who recently discontinued treatment due to pregnancy, presenting with progressive signs and symptoms of rapidly decompensating liver failure due to sinusoidal obstruction. Multimodality imaging was performed without evidence for focal hepatic metastatic disease; however, intrahepatic vein (IVC) compression was noted. Hepatic sinusoidal tumor infiltration was confirmed by liver biopsy. After palliative chemotherapy the disease became less infiltrative and more conspicuous on imaging, revealing itself as hepatic metastases, with decreased compression of the intrahepatic IVC and resolution of signs and symptoms of sinusoidal obstruction syndrome.

Erroneous diagnosis of primary fibrosarcoma of the breast: The value of the multidisciplinary breast team approach

Diagnostic errors occur in the preanalytic, analytic, and postanalytic phases of specimen processing. Correlating clinical and imaging information with gross and microscopic findings is crucial to limit errors and unnecessary treatment. Herein, we report the case of a 54-year-old woman who presented with left breast bloody nipple discharge and subsequently underwent central duct excision. Pathology revealed a high-grade sarcoma. The patient presented to our institution for further management. Upon secondary pathology review and DNA fingerprinting analysis, the correct interpretation was rendered. Our case demonstrates the importance of clinical correlation and review of pathology slides prior to definitive therapy.

Abstract PS3-09: The use of magnetic resonance imaging (MRI) in predicting pathological complete response(pCR) in the breast and axilla after the addition of immunotherapy to neoadjuvant systemic therapy (NST)

Introduction: Immunotherapy use is increasing as an adjunct to current NST for breast cancer treatment with the goals of increasing pCR and down staging tumors. In this study, we assessed the effectiveness of MRI in the evaluation of tumor response after neoadjuvant immunotherapy in combination with NST. Methods: We retrospectively reviewed the clinicopathological data of 105 women undergoing Immunotherapy in conjunction with NST at a single institution. All patients had been enrolled in IRB approved protocols and had undergone definitive surgery. Patients were excluded for: failure to complete at least two thirds of treatment, no pre or post treatment MRI, or surgery in an outside institution. We analyzed 73 patients from 5 distinct treatment protocols including: (1) 24 Triple negative breast cancer (TNBC) patients (pts) treated with Intratumoral Talimogene laherparepvec (TVEC) in combination with weekly paclitaxel followed by dose dense Adriamycin and Cytoxan (ddAC); (2) 19 HER2/Neu positive (HER2+) pts treated with subcutaneous interferon gamma (IFN-γ) in combination with weekly paclitaxel with trastuzumab and pertuzumab (HP); (3), 7 HER2+ pts treated with 3 weeks of HER2 pulsed dendritic cell vaccines (DC1) followed by Taxotere, Carboplatin, and HP; (4), 14 pts on the ISPY2 trial: 8 TNBC and 4 Hormone receptor positive, HER2/Neu negative (HR+) pts randomized to treatment with pembrolizumab with weekly paclitaxel followed by ddAC (2 also received additional SD101), and 2 TNBC pts treated with Durvalumab, Olaparib and Paclitaxel, followed by ddAC and (5) 9 HR+ pts on neoadjuvant Durvalumab and an Aromatase Inhibitor for 6 cycles. Results: A total of 73 patients were included in the study. Median age was 51 years (range 27-76); 46.6% of patients had TNBC, 35.6% had HER2+ and the remaining 17.8% were HR+ HER2-. The median clinical tumor size was 3.4cm (range 1.3-10.6) pre therapy and 1cm (range 0-10.1) post therapy. The pCR was 38.2%, 57.7%, and 0% respectively for TNBC, HER2+, HR+ tumors. Complete radiological response (rCR) of both the axilla and breast was 41.2%, 61.5% and 7.7%, for TNBC, HER2+ and HR+ tumors. The sensitivity of MRI to detect in breast pCR was 65.6% with a specificity of 81%, NPV and PPV of 75% and 73.3% respectively. MRI identified 37 pts with suspicious axillary nodes on pretreatment MRI; of these 30 had fine needle aspiration (FNA) confirmed metastatic disease. Post treatment, 70.3% (26/37) had normalized axillary nodes. Of those with normalized nodes, 26.9% (7/26) had residual cancer on final pathology. Of the patients with confirmed FNA lymph node metastasis, axillary pCR of 63.3% was achieved. The sensitivity and specificity of MRI to detect pCR within the axilla was 87% and 50% and NPV and PPV 70% and 74.1%, respectively. 3 patients had axillary disease on final pathology but no suspicious imaging and a benign FNA. Conclusion: The addition of immunotherapy to current NST strategies can improve pCR and decrease residual cancer burden. The PPV and NPV of MRI to predict pCR in patients undergoing immunotherapy in combination with NST remains within the ranges described in patients undergoing NST alone. MRI remains a useful tool to guide surgical management but is not accurate enough to replace pathological evaluation.

Citation Format: Noeline Rajarajan, Daniel Segarra, Robert J Weinfurtner, Adrian A Lopez, M Catherine Lee, John Kiluk, Hatem Soliman, Hung Khong, Han S Hyo, Marilin Rosa, Brian J Czerniecki, Nazanin Khakpour. The use of magnetic resonance imaging (MRI) in predicting pathological complete response(pCR) in the breast and axilla after the addition of immunotherapy to neoadjuvant systemic therapy (NST) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS3-09.

Adenomyoepithelioma of the breast: Case series and literature review

Adenomyoepithelioma of the breast is a rare tumor consisting of both epithelial and myoepithelial cells. Malignant transformation of either cell line can occur. We describe the imaging features, clinical presentation, and management of seven cases of biopsy-proven adenomyoepithelioma at our institution.

A Phase I Trial of Talimogene Laherparepvec in Combination with Neoadjuvant Chemotherapy for the Treatment of Nonmetastatic Triple-Negative Breast Cancer

PURPOSE

Talimogene laherparepvec (TVEC) is an oncolytic herpes simplex 1 virus approved for treatment of melanoma. We hypothesized intratumoral TVEC may enhance response to neoadjuvant chemotherapy (NAC). This article reports the results of a trial combining NAC with TVEC for triple-negative breast cancer (TNBC).

PATIENTS AND METHODS

Patients with stage II-III TNBC enrolled in a 3+3 phase I trial (NCT02779855) of two TVEC dose levels [DL; DL 1 = 10⁶ plaque-forming units (PFU) × 5 doses; DL 2 = 10⁶ PFUs first dose, then 10⁸ PFUs × 4 doses] on weeks 1, 4, 6, 8, and 10 plus weekly paclitaxel (80 mg/m²) for 12 weeks, followed by doxorubicin/cyclophosphamide (60/600 mg/m²) every 2 weeks for 8 weeks. Postoperative response assessment using residual cancer burden (RCB) was performed. Primary endpoints were safety and MTD. Secondary endpoints were RCB0 rate and immune correlates. Dose-limiting toxicity (DLT) rule was grade 3-5 adverse events due to TVEC during first 5 weeks.

RESULTS

Nine patients [DL 1 (n = 3); DL 2 (n = 6)] were enrolled. Six had stage II disease, and 3 had stage III (6 clinically N⁺). No DLTs occurred, and MTD was DL 2. Most common toxicities with TVEC were fever (n = 8), chills (n = 3), hematomas (n = 3), and injection site pain (n = 3). Thromboembolic events (n = 2) and bradycardia (n = 1) occurred during or after NAC. Five patients (55%) achieved RCB0, 2 had RCB1 (22%), and 2 had RCB2 (22%).

CONCLUSIONS

The addition of TVEC to NAC was feasible at the approved dose, with manageable toxicity. The complete response rate was 55%.

Diffuse Intrasinusoidal Hepatic Metastasis from Breast Cancer Presenting as Liver Failure: Effective and Rapid Treatment with Weekly Low-Dose Adriamycin

Patient: Female, 28-year-old

Final Diagnosis: Hepatic metastasis • metastatic breast cancer • sinusoidal occlusive syndrome

Symptoms: Abdominal distension • abdominal pain • lower extremity edema • nausea • vomiting

Medication:—

Clinical Procedure: —

Specialty: General and Internal Medicine • Oncology

Tumor size and focality in breast carcinoma: Analysis of concordance between radiological imaging modalities and pathological examination at a cancer center

CONTEXT

Accurate assessment of clinical and pathological tumor stage is crucial for patient treatment and prognosis.

OBJECTIVE

The aim of this study was to assess the concordance between the tumor size and focality between radiological studies and pathology and to evaluate the impact of discrepancies on staging.

DESIGN

Patients who underwent surgery for invasive breast carcinoma from January 1, 2014, to December 31, 2015, were identified.

RESULTS

Three imaging modalities (mammogram, ultrasound and MRI) were compared with gross examination and final pathology. 1152 preoperative radiological studies were evaluated for focality and 1019 were evaluated for tumor size. For all 3 radiographic modalities, there was a statistically significant difference between the mean tumor size on radiology and the final pathology report (mammogram, P < .001; ultrasound, P = .004; MRI, P < .001). In 29% of radiology studies, there was a discrepancy in stage. The error rate for determining focality was 28% for mammograms, 27% for ultrasounds, and 29% for MRIs. Tumor size from gross examination correlated with microscopic tumor size in 57% of cases, but gross examination had 88% concordance with the final pathology report in determining focality.

CONCLUSION

Our study revealed statistically significant differences in mean tumor size reported across all 3 imaging modalities when compared to the final pathology report. MRI had the highest error rate, with a tendency to overestimate tumor size and number of foci. Among all diagnoses, cases of invasive carcinoma with an extensive intraductal component were most prone to discrepancies with imaging.

Abstract CT185: A phase II neoadjuvant trial of Interferon-gamma plus weekly paclitaxel, trastuzumab and pertuzumab in patients with HER-2 positive breast cancer

Background: IFN-γ, a cytokine that plays diverse roles in innate and adaptive immunity, has been shown to be essential in anti-tumor immune response. In vitro and in vivo studies have shown the synergistic effect of IFN-γ in combination with HER2-targeting monoclonal antibodies with or without taxane chemotherapy. We previously conducted a phase I trial of IFN-γ in combination with paclitaxel, trastuzumab and pertuzumab (IPTP) in metastatic HER2-positive breast cancer (HER2+BC) based on which we initiated a phase II neoadjuvant study with this combination. Methods: Early stage HER2+BC patients were eligible. Treatment included 12 weeks of weekly paclitaxel 80 mg/m2 IV, trastuzumab IV every 3 weeks x 4 (8 mg/kg loading dose, then 6 mg/m2) and pertuzumab IV every 3 weeks x 4 (840 mg loading dose, then 420 mg) in combination with IFN-γ 50 mcg/m2 subcutaneous injection three times weekly starting on day 1. The primary objective was to evaluate the pathologic complete response rate (pCR) in breast and nodes. This study had a planned interim analysis after 23 patients were evaluable for pCR based on a Simon's two stage design with 90% power and a type I error rate of 0.1. The final proportion of hormone receptor (HR) status among accrued patients will be used for comparison to historical control because pCR is expected to be lower for HR+HER2+BC compared to HR-HER2+BC subtype (25% vs 50% respectively). Here we are reporting the planned interim analysis results. Results: Twenty three patients were enrolled between 1/2018 and 7/2019. Most patients had clinical stage II/III (86%) and 43% were clinically and pathologically node positive. Nineteen out of 23 (82%) had HR+ and 3 had invasive lobular carcinoma. The pCR for all patients was 52% (12/23). The pCR for HR+HER2+ and HR-HER2+ BC subgroup was 57% (11/19) and 25% (1/4) respectively. Further evaluation using RCB (residual cancer burden) showed 12 pts RCB-0, 5 RCB-I, 5 RCB-II, and 1 RCB-III. Two SAE included pneumonitis/heart failure and hematochezia. The most frequently observed grade 1 and 2 AEs were fatigue (69%), diarrhea (59%), rash (41%) and nausea (41%). Grade 3 toxicities (4% or higher) included diarrhea (n=3) and no grade 4 AE was noted.

Conclusion: The addition of IFN-γ to neoadjuvant chemotherapy using paclitaxel, trastuzumab and pertuzumab was well tolerated with manageable toxicities. This study evaluated de-escalated treatments only 12 weeks duration and the anthracycline-free regimen which was highly effective with pCR of 52%. The pCR for HR+HER2+BC subtype was 57% which compares favorably to the expected pCR of 25% with neoadjuvant chemotherapy alone in HR+HER2+ patients. This regimen met the criteria to proceed to the second stage of the phase II trial and appears promising especially in HR+HER2+BC. Updated results will be presented at the meeting including correlative studies.

Citation Format: Hyo S. Han, Dawn Goodridge, Avan Armaghani, Ricardo Costa, Aixa Soyano Muller, Loretta Loftus, Hatem Soliman, Brooke Fridley, Laila Khazai, Aiana Cerezo, Jesse Hevia, Marilin Rosa, Hung Khong, Brian Czerniecki. A phase II neoadjuvant trial of Interferon-gamma plus weekly paclitaxel, trastuzumab and pertuzumab in patients with HER-2 positive breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT185.

12-chemokine gene expression score in breast cancer patients treated with neoadjuvant chemotherapy

591

Background: Although advances in immunotherapy for the treatment of breast cancer have been minimal compared with other cancers, studies demonstrating tumor-infiltrating lymphocytes and immunomodulatory gene activation in the tumor microenvironment suggest the importance of antitumor immune responses in clinical outcomes. A 12-chemokine gene score has been shown to predict the presence of ectopic lymph node-like structures (ELN) in the tumor microenvironment and improved survival in melanoma, colon cancer, and breast cancer patients (Prabhakaran, 2017). Here, we evaluated this signature in an independent dataset of breast cancer patients treated with neoadjuvant chemotherapy. Methods: Tumor specimens used in this retrospective analysis (n = 92) were from breast cancer patients enrolled in either MINT (NCT0151487) or NBRST (NCT01479101) neoadjuvant registry trials from 2011 to 2016. Clinical data were captured with informed consent, and 70-gene signature (70-GS), 80-gene signature (80-GS), and full transcriptome data were generated by Agendia, Inc. Gene expression data were quantile normalized using R limma package. Principal component analysis (PCA) was performed on the normalized dataset using R princomp package. Chemokine score (CS) was defined as the first principal component values resulting from PCA. 70-GS/80-GS and clinical data were evaluated in relation to CS. CS were compared using Mann-Whitney test. Results: Of 92 breast tumors available for analysis, 84% were 70-GS High Risk (HR). Tumors were 39% Luminal-type, 24% HER2-type, and 32% Basal-type by 80-GS. HR tumors had higher CS than 70-GS Low Risk (LR) tumors (p < 0.001). 80-GS Basal-type, HER2-type, and Luminal B tumors had higher CS than Luminal A tumors (p < 0.01 for each comparison). High grade and ER-negative tumors seemed to have a high CS, although not significantly. Tumors from patients who achieved a pathological complete response (pCR) following neoadjuvant chemotherapy had higher CS than patients with residual cancer burden (p = 0.048). Conclusions: The current study demonstrated a significantly higher CS in 70-GS HR tumors and those which achieved pCR following neoadjuvant chemotherapy. Although further study is needed to evaluate the association of high CS with tumor-associated ELN, these results support previous work demonstrating that, although high CS is associated with aggressive clinical features, it also predicts superior clinical outcomes. The current study suggests validation of the 12-chemokine gene score in an independent dataset of breast cancer patients.

Abstract OT3-10-01: Phase Ib study of stereotactic radiation and nivolumab in the management of metastatic breast cancer with brain metastases

Background:Patients with breast cancer brain metastases represent a poor prognosis cohort with a high unmet clinical need. Standard-of-care treatments for patients with breast cancer brain metastases include local treatments, such as surgical resection and radiation treatment modalities that include stereotactic radiosurgery (SRS) or whole brain radiotherapy. Numerous pre-clinical studies have provided evidence to combine radiation therapy with immune checkpoint inhibition to improve response rates. The evidence is strongest for short course, hypofractionated radiation regimens. We hypothesize treatment with nivolumab and SRS will be feasible and well tolerated and may improve intracranial tumor control rates compared to SRS alone. Trial Design:The study is designed as a prospective, single-arm, nonrandomized, open-label, phase Ib trial of nivolumab and SRS among patients with metastatic breast cancer brain metastases. Treatment will be initiated with a dose of nivolumab (480 mg IV) that will be repeated every 4 weeks. The initial dose of nivolumab will be followed 1 week later by SRS at sites of brain metastases or post-operative cavities. Patients will be allowed to continue endocrine and HER2-targeted therapies if brain metastases progression was noted on these agents.Eligibility:Eligible patients include those ≥18, ECOG ≤2 with ≤10 breast cancer brain metastases of all subtypes eligible for stereotactic radiation. Specific Aims:The primary objective is to evaluate the safety and feasibility of nivolumab and SRS to sites of brain metastases. Secondary objectives include evaluation of intracranial progression free survival (PFS), extracranial PFS, overall survival, local control, and distant brain control. Correlative aims include assessing blood and tissue biomarkers (i.e. PD-L1, mutation burden, TCR repertoire etc.) for association with clinical benefit.Statistical Methods:Safety and feasibility will be monitored by a 3 + 3 design followed by a dose expansion phase. Patient Accrual:This study is open with 4 patients enrolled at the time of submission. A total of 12 patients will be enrolled.Contact Information:Kamran A. Ahmed MD, Moffitt Cancer Center, email: kamran.ahmed@moffitt.org, Clinical trial information: NCT03807765.

Citation Format: Kamran A Ahmed, Youngchul Kim, Avan J. Armaghani, John A. Arrington, Jimmy J. Caudell, Ricardo L. Costa, Brian J. Czerniecki, Arnold B. Etame, Peter A. Forsyth, Hung T. Khong, Sungjune Kim, Loretta Loftus, Timothy J. Robinson, Marilin Rosa, Solmaz Sahebjam, Hatem H. Soliman, Aixa E. Soyano, Nam D. Tran, H. Michael Yu, Hyo S. Han. Phase Ib study of stereotactic radiation and nivolumab in the management of metastatic breast cancer with brain metastases [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-10-01.

Suboptimal concordance in testing and retesting results of triple-negative breast carcinoma cases among laboratories: one institution experience

Background

Triple-negative breast carcinoma (TNBC) patients do not benefit from hormone- or human epidermal growth factor receptor 2- (HER2-) targeted therapies. Accurate testing is pivotal for these patients.

Methods

TNBC cases that were retested at our institution during a 3-year period were evaluated for concordance rates in estrogen (ER) and progesterone (PR) receptor and HER2 results.

Results

We found 19 (22%) discrepancies (13 major/6 minor) among 86 cases. Minor discrepancies were in HER2 changes by immunohistochemistry, and all cases were demonstrated to be negative by and dual in situ hybridization. All major discrepancies were in ER/PR expression changes. In only 2 cases the treatment changed based on repeated results and/or patient history.

Conclusions

Discrepancies in prognostic/predictive testing continue to be frequent despite rigorous regulations. However, since for the majority of patients in our setting, the treatment plan did not change, reflex retesting for TNBC has been deemed unnecessary in our institution.

Core needle biopsy of benign, borderline and in-situ problematic lesions of the breast: Diagnosis, differential diagnosis and immunohistochemistry

Core needle biopsy (CNB) is the most common sampling technique for the histologic evaluation of breast abnormalities. Diagnosing benign proliferative, borderline and some in-situ lesions in CNB is challenging and subject to a significant degree of interobserver variability. In addition, due to the inherent limitations of CNB, "upgrading" to a more significant pathology at excision is an important consideration for some lesions. Pathologists carry a major responsibility in patient diagnosis, risk stratification and management. Familiarity with the histologic features and the clinical significance of these common and problematic lesions encountered in CNB is necessary for adequate treatment and patient follow-up. This review will focus on benign, atypical and in-situ epithelial proliferations, papillary lesions, radial sclerosing lesions, adenosis and cellular fibroepithelial lesions. Highlights of histologic features, useful strategies for accurate diagnosis, basic immunohistochemistry and management will be presented.

Paediatric Orthodontics Part 1: Anterior open bite in the mixed dentition

The correction of anterior open bite in the mixed dentition: treatment or over-treatment? Early treatment of the anterior open bite is a common, widespread treatment, which involves sometimes multiple clinical procedures: active orthodontic treatment and correction of the dysfunctional habits with a large waste of financial and biological costs. Therefore, also considering the significant possibility of self-improvement in the pre-pubertal phase, active early treatment should not aim to the active correction of the AOB, but only to other aspects of the malocclusion and to the interception of dysfunctional habits.

Abstract OT2-04-05: Phase II trial of pre-operative stereotactic ablative radiotherapy (SABR) in early-stage breast cancer

Background:

Post-operative accelerated partial breast irradiation (APBI) has demonstrated efficacy in preventing in-breast tumor recurrence. Pre-operative administration of APBI may be advantageous as an intact breast tumor is smaller than its corresponding lumpectomy cavity, is easier to distinguish on treatment-planning images, and results in smaller and more accurately delineated target volumes. Pre-operative APBI may reduce the incidence of positive margins following breast-conserving surgery (BCS). Investigation is needed in the correlation of MR imaging with pathologic response 6 weeks after SABR. Also, evidence suggests that SABR induces immune activation in the tumor microenvironment; evaluation of excised tumor tissue will give insight into these processes.

Trial Design:

Treatment Planning and Delivery: CT simulation and treatment are performed in the prone position. Diagnostic MRI is fused to planning CT. GTV is delineated on registered breast MRI and includes the intact breast tumor. CTV is 15mm expansion of GTV. PTV is 3 mm expansion of CTV. VMAT or IMRT are permitted. Daily image-guidance aligning to tumor and biopsy-fiducial is mandatory. All subjects undergo pre-operative SABR to 28.5 Gy in 3 fractions of 9.5 Gy on different days separated by ≤48 hours. CTCAE v4 is used to assess toxicity 4-5 weeks after SABR. Pre-operative diagnostic MRI is performed 5-6 weeks following SABR. Imaging parameters to be evaluated include changes in tumor size, enhancement, and tumor margin description. BCS will be 6-8 weeks following SABR.

Tissue pathology: Margin status and degree of pathologic response are recorded from breast-conserving excisions, specimens are archived for future analysis.

Eligibility Criteria:

Inclusion criteria are women age ≥50 with biopsy proven invasive breast adenocarcinoma with tumor size ≤2cm on MRI, cN0 M0, ER+/HER2-, without history of invasive malignancy or prior breast/thoracic radiotherapy.

Exclusion criteria are active scleroderma or lupus erythematosus with skin involvement, MRI defined tumor within 10 mm of skin, implanted hardware prohibiting appropriate treatment planning or delivery, neoadjuvant chemotherapy, carrier of BRCA1 or 2 gene mutation, pregnancy.

Specific Aims:

The primary endpoint is pathologic complete response (pCR) in the breast tumor, secondary endpoints are incidence of adequate surgical margins (defined as “no tumor on ink”) and MRI response following SABR. Analyses of tumor immune response and microenvironment on pathologic specimens following SABR will also be performed.

Statistical Methods:

Fisher's exact test will be performed to examine associations between patient/tumor characteristics and pCR and surgical margins; these associations will be explored with multivariable logistic and linear regressions.

Accrual:

Present accrual is 9 subjects.

Expected accrual is 22 subjects; if ≥3 pCR are noted in the initial cohort, accrual will be expanded to 40 subjects.

Citation Format: Liveringhouse CL, Diaz R, Ahmed KA, Lee MC, Czerniecki B, Laronga C, Khakpour N, Weinfurtner RJ, Rosa M, Montejo ME. Phase II trial of pre-operative stereotactic ablative radiotherapy (SABR) in early-stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-05.

Diagnostic value of intraoperative rapid cytokeratin immunostain in the cytological evaluation of sentinel lymph nodes in patients with invasive lobular carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is the standard of practice in clinically node-negative patients with breast carcinoma. Intraoperative imprint cytology (IC) is often used in this setting. In cases of invasive lobular carcinoma (ILC), interpretation of IC slides may be challenging. Rapid cytokeratin immunohistochemistry (R-CK) has been used in this scenario. This study evaluated if the combination of IC and R-CK improves the sensitivity of intraoperative SLN evaluation of ILC in our setting.

METHODS

SLN of all cases of ILC in which IC and R-CK were performed in a 4 year period were included. Final tissue diagnosis was used as the gold standard.

RESULTS

Four hundred and twenty-seven of the 802 IC performed during the study period corresponded to paired IC and R-CK for ILC. Independently, IC and R-CK correctly classified the SLN as negative or positive in 355 cases (83%) and 324 (76%) cases, respectively. In combination, IC and R-CK correctly classified 304 (71%) of cases. R-CK failed in 56 cases. R-CK aided in rendering an accurate diagnosis in 59% of atypical cases (19/32). Patients with atypical IC and positive R-CK did not undergo axillary dissection. The addition of R-CK increased the turnaround time (TAT) by 24 minutes.

CONCLUSIONS

In this study, the addition of R-CK did not improve the diagnostic accuracy in cases classified as negative or positive by IC, but resulted in a considerable increase in TAT. Although R-CK proved to be of diagnostic value in atypical IC cases, it did not appear to influence clinical management.

Hyper-phosphorylation of Rb S249 together with CDK5R2/p39 overexpression are associated with impaired cell adhesion and epithelial-to-mesenchymal transition: Implications as a potential lung cancer grading and staging biomarker

Prediction of lung cancer metastasis relies on post-resection assessment of tumor histology, which is a severe limitation since only a minority of lung cancer patients are diagnosed with resectable disease. Therefore, characterization of metastasis-predicting biomarkers in pre-resection small biopsy specimens is urgently needed. Here we report a biomarker consisting of the phosphorylation of the retinoblastoma protein (Rb) on serine 249 combined with elevated p39 expression. This biomarker correlates with epithelial-to-mesenchymal transition traits in non-small cell lung carcinoma (NSCLC) cells. Immunohistochemistry staining of NSCLC tumor microarrays showed that strong phospho-Rb S249 staining positively correlated with tumor grade specifically in the squamous cell carcinoma (SCC) subtype. Strong immunoreactivity for p39 positively correlated with tumor stage, lymph node invasion, and distant metastases, also in SCC. Linear regression analyses showed that the combined scoring for phospho-Rb S249, p39 and E-cadherin in SCC is even more accurate at predicting tumor staging, relative to each score individually. We propose that combined immunohistochemistry staining of NSCLC samples for Rb phosphorylation on S249, p39, and E-cadherin protein expression could aid in the assessment of tumor staging and metastatic potential when tested in small primary tumor biopsies. The intense staining for phospho-Rb S249 that we observed in high grade SCC could also aid in the precise sub-classification of poorly differentiated SCCs.

Invasive Breast Carcinoma Tumor Size on Core Needle Biopsy: Analysis of Practice Patterns and Effect on Final Pathologic Tumor Stage

INTRODUCTION

In the absence of nodal metastasis, pathologic tumor (pT) size remains one of the most important factors in adjuvant treatment decisions and patient prognosis in breast cancer. The aim of this study was to evaluate the effect of core needle biopsy (CNB) tumor size on final pT stage.

MATERIALS AND METHODS

Our information system was searched to identify all patients who underwent excisional procedures for invasive breast carcinoma from January 1^, 2014 to December 31, 2015. The tumor size on CNB and final excision, the number of cases in which the CNB size was larger, and the percentage of cases in which using the CNB tumor size changed the final pT stage were recorded.

RESULTS

From 1380 primary breast excisions/mastectomies, a total of 870 cases were included. In 82 (9.4%) the CNB tumor size was larger (63 of 82 cases) or no residual tumor was identified on excision (19 of 82 cases). From these 82 cases, 40 (48.7%) were properly staged on the basis of CNB tumor size, 16 (19.5%) were not staged, and 26 (31.7%) were staged using the final excision tumor size. Change in stage occurred in 7 of these 26 patients.

CONCLUSION

Our study revealed that in most cases, the largest tumor size is found in the excision/mastectomy specimen. However, in 9.4% (82 of 870), the CNB contains the most accurate tumor size for pT staging. On the basis of our results, including the largest linear tumor extent on the CNB report is recommended.

A Nonlinear Circuit Architecture for Magnetoencephalographic Signal Analysis

Objectives: The objective of this paper was to face the complex spatio-temporal dynamics shown by Magnetoencephalography (MEG) data by applying a nonlinear distributed approach for the Blind Sources Separation. The effort was to characterize and differentiate the phases of a yogic respiratory exercise used in the treatment of obsessive compulsive disorders.

Methods: The patient performed a precise respiratory protocol, at one breath per minute for 31 minutes, with 10 minutes resting phase before and after. The two steps of classical Independent Component Approach have been performed by using a Cellular Neural Network with two sets of templates. The choice of the couple of suitable templates has been carried out using genetic algorithm optimization techniques.

Results: Performing BSS with a nonlinear distributed approach, the outputs of the CNN have been compared to the ICA ones. In all the protocol phases, the main components founded with CNN have similar trends compared with that ones obtained with ICA. Moreover, using this distributed approach, a spatial location has been associated to each component.

Conclusions: To underline the spatio-temporal and the nonlinearly of the neural process a distributed nonlinear architecture has been proposed. This strategy has been designed in order to overcome the hypothesis of linear combination among the sources signals, that is characteristic of the ICA approach, taking advantage of the spatial information.

Evaluation of Expression of Human Epidermal Growth Factor Receptor 2 (HER2) in Gastric and Gastroesophageal Junction Adenocarcinoma Using IHC and Dual-ISH

BACKGROUND/AIM

Trastuzumab® is used for human epidermal growth factor receptor 2 (HER2)-overexpressing metastatic gastric/gastroesophageal junction (GEJ) adenocarcinoma. Our aim was to compare HER2 expression by immunohistochemistry (IHC) and dual in situ hybridization (DISH) in early-stage vs. late-stage gastric and GEJ tumors.

MATERIALS AND METHODS

Fifty early-stage and 50 late-stage gastric tumors and a similar number of early-stage and late-stage GEJ tumors were studied. HER2 was analyzed by IHC and dual-ISH using tissue microarray.

RESULTS

Of 200 selected cases, 168 had satisfactory results. Among the 110 cases with both tests successfully performed, there were only five cases with discrepancy between assays (4.5%). Seven equivocal (2+) cases by IHC were all found to be amplified by dual-ISH. When compared with IHC, dual-ISH identified 12 additional HER2-positive cases (10.9%).

CONCLUSION

The 12.5% overall overexpression/amplification in gastric and GEJ adenocarcinomas is in concordance with previous reports. No correlation was found between tumor stage and HER2 overexpression/amplification. Determination of HER2 in limited tissue samples benefits from combinational IHC and ISH testing.

Occult Breast Carcinoma Presenting as Scalp Metastasis

Breast cancer is the most common tumor among women, and approximately 6% of the patients have de novo metastatic breast cancer. Occult breast cancer accounts for only 0.1–0.8% of the cases and most commonly presents with axillary lymphadenopathy. Scalp metastases are rare and have been described as a sign of progression or widespread metastatic disease. Here, we describe a rare case of de novo metastatic breast cancer to the scalp as the single site of spread and without an identifiable primary breast tumor.