Invasive Lobular Carcinoma-Correlation Between Imaging and Final Pathology: Is MRI Better?

BACKGROUND

Invasive lobular carcinoma (ILC) is associated with high re-excision rates following breast-conserving surgery (BCS). The correlation between lesion size on different imaging modalities and final tumor size has not been well characterized.

METHODS

A prospective database of patients with stage I-III breast cancer undergoing BCS between 2006 and 2016 was reviewed. Pearson correlation analysis was used to correlate tumor size on breast imaging to final pathology.

RESULTS

Of these, 111 patients with ILC were identified. Mean lesion size was 1.93 cm for MMG, 1.61 cm for US, and 2.51 cm for MRI. Mean tumor size on surgical excision was 2.64 cm. The correlation coefficient between pathology and the different imaging modalities were as follows: MMG .17, US 0.37, and MRI .58. Actual tumor size was underestimated by 1 cm in 27.1% of MMGs, 50% of USs, and in 13.3% of MRIs. 38 patients (34.2%) underwent re-excision. No differences in re-excision rates were noted in patients with and without MRI, 30.3% vs 40.0%, respectively (P = .31).

CONCLUSION

While MRI provides a better estimate of tumor size than MMG and US, the size of the tumor on imaging only weakly correlated with pathology. The use of MRI does not decrease re-excision rates.

Abstract P4-07-32: Mammaprint and Blueprint are prognostic of outcome following neoadjuvant chemotherapy

Introduction: Neoadjuvant chemotherapy (NAC) is used increasingly in patients with early-stage breast cancer (EBC). Genomic approaches are necessary to identify better biomarkers that can more accurately predict response to NAC and outcome. The impact of NAC on the molecular biology of breast tumors, especially in patients that fail to respond to treatment, is not well studied. We evaluated the risk of distant recurrence signature, MammaPrint (MP), and the molecular subtyping signature, BluePrint (BP), in the neoadjuvant setting and how the prognostic capability of MP and BP, which was validated on untreated biopsies, is affected by NAC in patients with residual disease. Methods: This analysis included 128 women (median age 50) with stage I-III EBC, of any clinical subtype, diagnosed from 2007-2016 who received NAC at Cedars-Sinai Medical Center. Of 128 patients, 73 had core needle biopsies available before treatment, 17 had surgically resected biopsies with residual disease available after treatment, and 38 with residual disease had paired pre- and post-treatment biopsies. MP classified tumors as High Risk (MP-HR) or Low Risk (MP-LR). MP and BP classified tumors as Luminal A (MP-LR), Luminal B (MP-HR), HER2, or Basal. The primary outcomes were pathological complete response (pCR), recurrence free survival (RFS), distant-metastasis free survival (DMFS), and overall survival (OS). The median follow-up time was 5.2 years. Differences between unmatched independent variables were examined by chi-square test or Fisher’s exact test. Differences in pCR rate were assessed by two-sided proportional z-test. For matched samples, McNemar’s test or Bowker’s test was used. Univariate survival analyses were evaluated using a Cox proportional hazards model. Results: Among 111 pre-treated tumors, MP-HR tumors had a significantly higher pCR rate (40.6%; n=39/96) compared to MP-LR tumors (13.3%; n=2/15; p=0.042). BP HER2 and Basal tumors had significantly higher pCR rates (56.8%; n=25/44 and 45.8%; n=11/24, respectively), compared to Luminal B tumors (16.1%; n=5/31; p<0.001 and p = 0.016 respectively). No Luminal A tumors (n=12) achieved pCR. MP-HR and BP Basal tumors were associated with a higher risk of recurrence or death than MP-LR and Luminal tumors. Among all 128 tumors, post-treated samples were more likely to be classified as MP-LR than pre-treated samples (45.5%; n=25/55 vs. 13.5%; n=15/111), whereas BP subtype distribution was similar. Among 38 paired samples with residual disease, BP subtype did not significantly differ after NAC (p=0.392) and had 92% concordance between pre- and post-treated samples. Basal tumors, whether classified before or after NAC was significantly associated with a RFS (HR=4.79, 95% CI 1.09-20.97; p=0.038), DMFS (HR=4.86, 95% CI 1.28-18.64; p=0.018), or OS event (HR=22.03, 95% CI 2.41-201.26; p=0.006) compared to luminal tumors. A significant number (26%; n=10; p=0.002) of tumors had discordant MP risk between pre- and post-treatment samples, all of which reclassified from MP-HR (Luminal B) to MP-LR (Luminal A). MP-HR tumors that reclassified as MP-LR after NAC had better 5-year OS (100%) compared to tumors that remained MP-HR (73.3%, 95% CI 47.2 - 87.9). Conclusions: MP and BP accurately predicted chemosensitivity and outcomes in NAC treated patients. Activated molecular pathways captured by BP classification remained stable after NAC treatment, with a high concordance rate. Approximately 1 out of 4 Luminal B (MP-HR) tumors reclassified as Luminal A (MP-LR) after NAC and have improved 5-year outcome compared to tumors that remained MP-HR. Together, this preliminary evidence supports the prognostic accuracy of MP and BP on tumors following NAC treatment. Future studies will study the effect of NAC on the BC transcriptome and their association with clinical outcomes.

Citation Format: Alice P. Chung, Marissa Srour, Farnaz Dadmanesh, Sungjin Kim, Armando Giuliano, Jennifer Wei, Yen Huynh, Shiyu Wang, Andrea Menicucci, William Audeh. Mammaprint and Blueprint are prognostic of outcome following neoadjuvant chemotherapy [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 P4-07-32.

Commission on Cancer CP3R Compliance Rates for Treatment of Patients With Triple Negative and HER2+ Breast Cancer: A National Cancer Database Analysis

BACKGROUND

Cancer Program Practice Profile Reports (CP3R) metrics were released by the Commission on Cancer to provide standards for high-quality care. One metric is the recommendation of combination chemotherapy or chemo-immunotherapy (CIT) within 120 days of diagnosis for women under 70 with AJCC T1cN0M0 or Stage IB-III HER2+ or hormone receptor negative breast cancer ([Multi-agent chemotherapy] MAC). Our study assesses national concordance rates for MAC and CIT.

METHODS

The National Cancer Database was queried from 2004-2014.

RESULTS

122,045 patients met criteria, of whom treatment for 101,800 (83.4%) patients was concordant with MAC and CIT. Treatment concordance increased from 75.7% in 2004 to 89.5% in 2014. For HER2+ patients, use of CIT treatment downtrended with progression of pathological stage, from 70.1% (stage I) to 58.1% (stage III). Mean overall survival of patients whose treatment was concordant with MAC and CIT was longer than that of patients who were non-concordant (146.6 vs 143.8 months, P <.01). On Cox regression, there was a survival benefit for concordant patients who were treated at academic hospitals (HR .89, 95% CI 0.802-.976) and had private insurance (HR .76, 95% CI 0.65-.89).

CONCLUSION

Compliance with MAC and CIT has improved over the past decade and is associated with a significant improvement in overall survival.

Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study

Genetically determined leukoencephalopathies comprise a group of rare inherited white matter disorders. The majority are progressive diseases resulting in early death. We performed a cross-sectional pilot study including 55 parents from 36 families to assess the level of stress experienced by parents of patients with genetically determined leukoencephalopathies, aged 1 month to 12 years. Thirty-four mothers and 21 fathers completed the Parenting Stress Index-4th Edition. One demographic questionnaire was completed per family. Detailed clinical data was gathered on all patients. Statistical analysis was performed with total stress percentile score as the primary outcome. Mothers and fathers had significantly higher stress levels compared with the normative sample; 20% of parents had high levels of stress whereas 11% had clinically significant levels of stress. Mothers and fathers had comparable total stress percentile scores. We identified pediatric behavioral difficulties and gross motor function to be factors influencing stress in mothers. Our study is the first to examine parental stress in this population and highlights the need for parental support early in the disease course. In this pilot study, we demonstrated that using the Parenting Stress Index-4th Edition to assess stress levels in parents of patients with genetically determined leukoencephalopathies is feasible, leads to valuable and actionable results, and should be used in larger, prospective studies.

Walking Under the Influence : Association of Time of the Day With the Incidence and Outcomes of Intoxicated Pedestrians Struck by Vehicles

AIM

Pedestrian fatalities commonly involve alcohol. We sought to characterize alcohol intoxication among pedestrians struck by vehicles and examine correlations between admission time and injury severity.

METHODS

The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for pedestrians struck by vehicles over a 16-year period starting January 2000. Subjects aged ≥18 years with available time and day of admission were selected. Patients with available blood alcohol content (BAC) were analyzed and those with positive (+) BAC (≥ 0.01%) were compared with those with negative (-) BAC. The primary outcome was mortality.

RESULT

35 840 patients met criteria, with 12 122 (33.8%) tested for BAC. 71.2% were (+) BAC. The proportion of (+) BAC pedestrians peaked at 02:00 (48.9% of admitted pedestrians, 88.5% of BAC tested pedestrians). Patients with a (+) BAC were more likely hypotensive (3.5% vs 2.7%, P = .019) and admitted with a Glasgow Coma Scale ≤ 8 (9.4% vs 7.1%, P < .001). Overall mortality was 4.6%. Those admitted from 06:00 to 11:00 had the highest odds of mortality in (+) BAC patients (4.7%, adjusted odds ratio 3.16, adjusted P < .001).

CONCLUSION

Pedestrians struck by vehicles during late hours are commonly intoxicated. These findings could help legislators to implement changes and strategies to decrease the risk and burden of injury in intoxicated pedestrians.

Structural brain anomalies in Cri-du-Chat syndrome: MRI findings in 14 patients and possible genotype-phenotype correlations

INTRODUCTION

Cri-du-Chat Syndrome (CdCS) is a genetic condition due to deletions showing different breakpoints encompassing a critical region on the short arm of chromosome 5, located between p15.2 and p15.3, first defined by Niebuhr in 1978. The classic phenotype includes a characteristic cry, peculiar facies, microcephaly, growth retardation, hypotonia, speech and psychomotor delay and intellectual disability. A wide spectrum of clinical manifestations can be attributed to differences in size and localization of the 5p deletion. Several critical regions related to some of the main features (such as cry, peculiar facies, developmental delay) have been identified. The aim of this study is to further define the genotype-phenotype correlations in CdCS with particular regards to the specific neuroradiological findings.

PATIENTS AND METHODS

Fourteen patients with 5p deletions have been included in the present study. Neuroimaging studies were conducted using brain Magnetic Resonance Imaging (MRI). Genetic testing was performed by means of comparative genomic hybridization (CGH) array at 130 kb resolution.

RESULTS

MRI analyses showed that isolated pontine hypoplasia is the most common finding, followed by vermian hypoplasia, ventricular anomalies, abnormal basal angle, widening of cavum sellae, increased signal of white matter, corpus callosum anomalies, and anomalies of cortical development. Chromosomal microarray analysis identified deletions ranging in size from 11,6 to 33,8 Mb on the short arm of chromosome 5. Then, we took into consideration the overlapping and non-overlapping deleted regions. The goal was to establish a correlation between the deleted segments and the neuroradiological features of our patients.

CONCLUSIONS

Performing MRI on all the patients in our cohort, allowed us to expand the neuroradiological phenotype in CdCS. Moreover, possible critical regions associated to characteristic MRI findings have been identified.

Firearm legislation, gun violence, and mortality in children and young adults: A retrospective cohort study of 27,566 children in the USA

BACKGROUND

Firearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested.

MATERIALS AND METHODS

The Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race.

RESULTS

27,566 children analyzed in the study. Most were adolescents aged 15-19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R² = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0-4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0-4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p < 0.001), and firearm injury type (p = 0.001) were associated with mortality; Hispanics (OR 1.36, 95% CI: 1.03-1.78), children age 5-9 (2.03, 1.30-3.17) and suicide attempts (15.6, 11.6-20.9) had higher odds of in-hospital mortality.

CONCLUSIONS

Firearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children.

[Management of wet AMD in France in 2015]

PURPOSE AND CONTEXT

Intravitreal administration of anti-VEGF agents, available in France since 2007, allows stabilization and improvement in visual acuity in wet age-related macular degeneration (AMD). In the past few years, the management of this disease has evolved in terms of both diagnostic methods and treatment schedules, which have been adapted to the pathophysiology of AMD. The goal of this survey, performed in a representative sample of French ophthalmologists, was to describe the evolution of medical practices one year after a similar survey (Massé et al., J Fr Ophtalmol 2016; 39: 40-7).

METHOD

The survey was performed from December, 2014 to March, 2015 in 191 ophthalmologists (53 general ophthalmologists and 98 retina specialists) with an on-line questionnaire. This questionnaire was designed by a committee of ophthalmologists to describe practices concerning screening, diagnosis, treatment and follow-up of wet AMD.

RESULTS

An initial intravitreal injection of an anti-VEGF agent was usually performed within 10 days after the diagnosis of wet AMD by 98% of ophthalmologists and within 5 days by 63%. The treatment protocols favored by retina specialists were pro re nata (PRN) for 58%, Observe and Plan for 25% and Treat and Extend for 17%. Bilateral intravitreal injections were performed on the same day by 46% of retina specialists, mostly for the convenience of the patient and because of the low infectious risk. The initial protocol was maintained by one third of retina specialists throughout the course of treatment, while two thirds of them reported that they reassessed the protocol on average after 5 months.

CONCLUSION

This survey on the practices of the ophthalmologists in wet AMD highlights an improvement in the time course of patient management and an evolution of treatment schedules toward individualized protocols.

A homozygous mutation in SLC1A4 in siblings with severe intellectual disability and microcephaly

We performed exome analysis in two affected siblings with severe intellectual disability (ID), microcephaly and spasticity from an Ashkenazi Jewish consanguineous family. We identified only one rare variant, a missense in SLC1A4 (c. 766G>A [p. E256K]), that is homozygous in both siblings but not in any of their 11 unaffected siblings or their parents (Logarithm of odds, LOD score: 2.6). This variant is predicted damaging. We genotyped 450 controls of Ashkenazi Jewish ancestry and identified only 5 individuals who are heterozygous for this variant (minor allele frequency: 0.0056). SLC1A4 (ASCT1) encodes a transporter for neutral aminoacids such as alanine, serine, cysteine and threonine. L-Serine is essential for neuronal survival and differentiation. Indeed, L-serine biosynthesis disorders affect brain development and cause severe ID. In the brain, L-serine is synthesized in astrocytes but not in neurons. It has been proposed that ASCT1 mediates the uptake of L-serine into neurons and the release of glia-borne L-serine to neighboring cells. SLC1A4 disruption may thus impair brain development and function by decreasing the levels of L-serine in neurons. The identification of additional families with mutations in SLC1A4 would be necessary to confirm its involvement in ID.

Mortality by Decade in Trauma Patients with Glasgow Coma Scale 3

The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.

Mortality by decade in trauma patients with Glasgow Coma Scale 3

The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.

Array comparative genomic hybridization in global developmental delay

OBJECTIVE

Array-based comparative genomic hybridization (array CGH) is an emerging technology that allows for the genome-wide detection of DNA copy number changes (CNC) such as deletions or duplications. In this study, array-based CGH was applied to a consecutive series of children with previously undiagnosed non-syndromal global developmental delay (GDD) to assess potential etiologic yield.

METHODS

The children in this study were drawn from a previously reported consecutive series of children with well-defined GDD. Almost all subjects had undergone prior karyotyping and neuroimaging studies with non-diagnostic results. Array-based CGH was undertaken using the SignatureChip(R) (1887 BACs representing 622 loci) with abnormalities verified by subsequent FISH analysis and testing of parents to distinguish between pathogenic and familial non-pathogenic variants.

RESULTS

On CGH analysis in our study, 6 of 94 children (6.4%) had a causally related pathogenic CNC. Three were sub-telomeric in location. An analysis of a variety of clinical factors revealed that only the presence of minor dysmorphic features (<3) was predictive of etiologic yield on CGH analysis (4/26 vs. 2/68, P = 0.05). Severity of delay was not found to be predictive.

INTERPRETATION

In children with non-syndromal GDD, array-based CGH has an etiologic yield of 6.4%. This suggests that this emerging technology may be of diagnostic value when applied subsequent to detailed history, physical examination, and targeted laboratory testing. Array CGH may merit consideration as a first-tier test in the context of a child with unexplained GDD.

A novel tetracycline-controlled transactivator-transrepressor system enables external control of oncolytic adenovirus replication

The use of restricted replication-competent adenoviruses (RRCAs) inducing tumor cell-specific lysis is a promising approach in cancer gene therapy. However, the use of RRCAs in humans carries considerable risk, since after injection into the patient, further regulation or inhibition of virus replication from the outside is impossible. Therefore, we have developed a novel system allowing external pharmacological control of RRCA replication. We show here that a tumor-selective E1B-deleted RRCA can be tightly regulated by use of doxycycline (dox)-controlled adenoviral E1A gene expression, which in turn determines vector replication. RRCA replication is switched on by addition and switched off by withdrawal of dox. The system results in efficient tumor cell killing after induction by dox, whereas cells are unaffected by the uninduced system. It was also employed for efficient external control of transgene expression from cotransfected replication-deficient adenovectors. Furthermore, the use of a liver cell-specific human alpha1-antitrypsin (hAAT)-promoter driving a tetracycline-controlled transcriptional silencer allowed specific protection of cells with hAAT-promoter activity in the absence of dox in vitro and in vivo, delineating a new principle of 'tissue protective' gene therapy. The concept of external control of RRCAs may help to improve the safety of cancer gene therapy.

Screening of some Palestinian medicinal plants for antibacterial activity

Antibacterial activity of organic and aqueous extracts of 15 Palestinian medicinal plants were carried against eight different species of bacteria: Bacillus subtilis, two Escherichia coli species, Staphylococcus aureus (methicillin resistant), two S. aureus (methicillin sensitive) species, Pseudomonas aeruginosa, and Enterococcus fecalis. Of the 15 plants tested, eight showed antibacterial activity. Each plant species has unique against different bacteria. The most active antibacterial plants against both gram-positive and gram-negative bacteria were Thymus vulgaris and Thymus origanium. The organic and aqueous extract from the same plants showed different activities; the organic extract showed the same or greater activity than the aqueous extract. Finally, the hole-plate diffusion method showed larger activity than the disc diffusion method.

A method for obtaining repeatable measurements of the tensile properties of skin at low strain

Initial attempts at measuring the low strain tensile properties of skin led to results which were not repeatable. It appeared that strains induced in the sample due to the handling needed to mount it in a simple clamp led to the low precision of the test. A new method which minimized the manipulation needed to mount a sample in a testing machine was then developed. Using this method the skin was aligned with a set of grips in a saline bath. When aligned, the saline was removed and the sample clamped in the grips without the need for additional handling. This approach produced a marked improvement in the repeatability of the tensile properties of skin at low strains.