Clinical impact and characteristics of erythroid dysplasia in adult aplastic anaemia: Results from a multicentre registry

Morphological dysplasia in haematopoietic cells, defined by a 10% threshold in each lineage, is one of the diagnostic criteria for myelodysplastic neoplasms. Dysplasia limited to the erythroid lineage has also been reported in some cases of aplastic anaemia (AA); however, its significance remains unclear. We herein examined the impact of erythroid dysplasia on immunosuppressive therapy responses and survival in AA patients. The present study included 100 eligible AA patients without ring sideroblasts. Among them, 32 had dysplasia in the erythroid lineage (AA with minimal dysplasia [mini-D]). No significant sex or age differences were observed between AA groups with and without erythroid dysplasia. In severe/very severe AA and non-severe AA patients, a response to anti-thymocyte globulin + ciclosporin within 12 months was observed in 80.0% and 60.0% of AA with mini-D and 42.9% and 90.0% of those without dysplasia, with no significant difference (p = 0.29 and p = 0.24 respectively). Overall survival and leukaemia-free survival did not significantly differ between the groups. Collectively, the present results indicate that the presence of erythroid dysplasia did not significantly affect clinical characteristics or outcomes in AA patients, suggesting that its presence in AA is acceptable. Therefore, erythroid dysplasia should not exclude an AA diagnosis.

COVID-19 antibody titers after tixagevimab-cilgavimab injection in patients with hematologic diseases; a single-center, prospective study

Knowledge of the SARS-CoV-2 antibody titers induced by tixagevimab-cilgavimab in patients with hematologic diseases remains insufficient. Here, we performed a single-center, prospective study to reveal the changes in antibody titer after administration of tixagevimab-cilgavimab in 78 patients with hematologic diseases. The median peak titer was 155.4 U/mL, and the median AUC was 46556 days·U/mL. First, we compared several characteristics between patients with low titers (peak titer ≤ 155.4 U/mL) and high titers (peak titer > 155.4 U/mL). We extracted 6 factors (patient age, sex, ECOG-PS, serum albumin level, and cross-sectional area and computed tomographic number of the psoas major muscle) as candidates influencing the antibody titers. Multiple regression analysis revealed that antibody titer was closely associated with these 6 factors (contribution rate = 0.76, p = 0.02). Our data support the inability of tixagevimab-cilgavimab to induce sufficient antibody titers against SARS-CoV-2, especially in older, frailer, female patients.

Successful treatment of isolated central nervous system recurrence of primary testicular lymphoma by autologous stem cell transplantation using a conditioning regimen of thiotepa and busulfan

Primary testicular lymphoma (PTL) frequently relapses in the central nervous system (CNS) despite prophylactic intrathecal chemotherapy, and the outcome for CNS recurrence of PTL is very poor. We report a case of isolated CNS recurrence of bilateral PTL. Our patient achieved complete response (CR) after rituximab-combination chemotherapy for PTL. Approximately five years later, isolated CNS recurrence of PTL occurred. Our patient achieved CR again after high-dose methotrexate therapy and autologous stem cell transplantation (ASCT) with a conditioning regimen of thiotepa and busulfan as a consolidation therapy. The secondary failure of platelet recovery, probably caused by busulfan, occurred after the platelet engraftment. Our patient has remained in CR for over three years. The treatment strategy for CNS recurrence of PTL is mainly whole-brain radiotherapy or high-dose methotrexate-based chemotherapy; however, CNS recurrence of PTL may occur again even after achieving CR. ASCT with a conditioning regimen of thiotepa and busulfan is the optimal consolidation therapy for secondary CNS lymphoma. To the best of our knowledge, this is the second reported case of a patient with isolated CNS recurrence of PTL successfully treated by ASCT with a conditioning regimen of thiotepa and busulfan as a consolidation therapy.

Sustained remission after cord blood transplantation for breast cancer with lung metastases and myelodysplastic syndrome

Allogenic hematopoietic stem cell transplantation (allo-HSCT) is not a standard therapy for solid cancer because of its high toxicity and insufficient evidence levels. However, the potential graft-versus-solid-tumor (GVT) effect of this therapy has been discussed. Many case reports have also described treatment effects of allo-HSCT in patients with hematologic malignancies and active solid tumors. A 38-year-old woman treated with fulvestrant and abemaciclib for recurrent breast cancer with multiple lung metastases was diagnosed with myelodysplastic syndrome (MDS) with increased blasts 2. She was classified as adverse risk by the 2017 European LeukemiaNet risk stratification and as very high risk by the Molecular International Prognostic Scoring System. Breast cancer treatment was interrupted and venetoclax and azacitidine therapy was started. Complete hematologic response was achieved after three cycles. However, multiple lung metastases from the breast cancer remained. The patient then underwent umbilical cord blood transplantation. She has maintained complete remission of MDS as of 1 year post-transplantation, without serious complications. Lung metastatic activity on FDG-PET/CT scan also completely disappeared by half a year post-transplantation, and this response has continued as of 1 year post-transplantation. This favorable treatment course suggests the existence of a GVT effect.

Efficacy of elotuzumab for multiple myeloma deteriorates after daratumumab: a multicenter retrospective study

Elotuzumab-based regimens are sometimes selected for multiple myeloma treatment after daratumumab-based regimens. However, there has been insufficient discussion on the efficacy of elotuzumab after daratumumab. We used Kansai Myeloma Forum registration data in a multicenter retrospective evaluation of the efficacy of elotuzumab after daratumumab. Overall survival (OS) rate and time to next treatment (TTNT) were significantly worse in the cohort given elotuzumab after daratumumab (Dara cohort, n = 47) than in the cohort with no history of daratumumab administration before elotuzumab (No-Dara cohort, n = 80, OS: P = 0.03; TTNT: P = 0.02; best response: P < 0.01). In the Dara cohort, OS and TTNT rates were worse with sequential elotuzumab use after daratumumab than with non-sequential (OS: P = 0.02; TTNT: P = 0.03). In patients given elotuzumab < 180 days after daratumumab, OS (P = 0.08) and best response (P = 0.21) tended to be worse, and TTNT was significantly worse (P = 0.01), than in those given elotuzumab after ≥ 180 days. These findings were confirmed by subgroup analyses and multivariate analyses. Monoclonal-antibody-free treatment might be preferable after daratumumab-based regimens. If possible, elotuzumab-based regimens should be considered only ≥ 180 days after daratumumab use.

Recurrence of solitary plasmacytoma in the liver 10 years after the onset of multiple bone lesions

A 79-year-old man presented with a history of solitary plasmacytoma in the bone 10 years ago. Chemoradiotherapy was effective, and remission was maintained with intermittent treatment at relapse of the bone lesions. One year after the last treatment, a follow-up computed tomography (CT) scan revealed multiple liver masses, and a liver biopsy revealed plasmacytoma. There was no clonal plasma cell infiltration in the bone marrow, and the final diagnosis was solitary plasmacytomas of the liver. Although liver involvement is known in relapsed refractory multiple myeloma, solitary plasmacytoma in the relapsed stage confined to the liver is rare, and all previous reports have been from the initial presentation. To the best of our knowledge, this is the first recurrent case of solitary plasmacytoma of the liver.

Effects of combined test dose and therapeutic drug monitoring strategy in exposure-directed busulfan

Although exposure-directed busulfan (BU) dosing can improve allogeneic hematopoietic stem cell transplantation outcomes, there is still large variability in BU exposure with test dose alone due to changes in BU clearance caused by drug interactions. We conducted a single-arm phase II trial using the combined test dose and therapeutic drug monitoring strategy (PK-guided group) and compared the outcomes with an external historical cohort receiving a fixed-dose (fixed-dose group). The first eight and second eight doses were adjusted based on the area under the blood concentration-time curve (AUC) of the test and first doses, respectively, targeting a total AUC of 82.1 mg·h/L. All patients received either BU and cyclophosphamide conditioning (BU/CY) or fludarabine (FLU)-containing conditioning. The BU clearance at the first dose decreased more in patients receiving FLU than in those receiving BU/CY; however, BU clearance also declined over time in patients who received BU/CY. The simulated total AUC (sAUC) with test dose only was significantly higher in patients who received FLU than in those who received BU/CY, but sAUC with the combined strategy was comparable. The 100-day progression-free survival was 85.5% (95% confidence interval [CI]: 71.9-92.8%), and was not inferior to that in the fixed-dose group. For the FLU-containing regimens, the PK-guided group showed decreased relapse (0.0% vs. 26.9%, p = 0.03), and favorable overall survival (75.1% vs. 57.0%, p = 0.07) at 1 year. The combined strategy effectively controlled the BU exposure close to the target levels, potentially improving efficacy, especially in patients receiving the FLU-containing regimen. Clinical evaluation of efficacy of dose-modified intravenous busulfan in allogeneic hematopoietic stem cell transplantation for hematological malignancy (#UMIN000014077, June 15th, 2014).

Epitope mismatch at HLA-DRB1 associates with reduced relapse risk in cord blood transplant for standard-risk hematological malignancy

BACKGROUND

Cord blood transplantation (CBT) is an attractive therapeutic option for patients with hematological malignancies. CBT tolerates HLA mismatches between donors and recipients, but which HLA mismatches generate graft-versus-tumor (GVT) effects is unknown.

OBJECTIVE

Given that HLA molecules contain epitopes comprising polymorphic amino acids that determine their immunogenicity, we investigated associations between epitope-level HLA mismatches and relapse following single-unit CBT.

STUDY DESIGN

A total of 492 patients with hematological malignancies who received single unit, T cell replete CBT were included in this multi-center retrospective study. HLA epitope mismatches (EM) were quantified using HLA matchmaker software from donor and patient HLA-A, B, C and DRB1 allele data. Patients were dichotomized by median EM value and divided into groups transplanted in complete/partial remission (standard stage: 62.4%) and others (advanced stage: 37.6%).

RESULTS

Median EM numbers in the graft-versus-host direction (GVH-EM) at HLA-class I and HLA-DRB1 were 3 (range, 0-16) and 1 (range, 0-7), respectively. Higher HLA-class I GVH-EM increased non-relapse mortality (NRM) in the advanced stage group (adjusted hazard ratio [HR], 2.12; p=0.021), with no significant advantage for relapse in either stage. On the other hand, higher HLA-DRB1 GVH-EM was associated with better disease-free survival in the standard stage group (adjusted HR, 0.63; p=0.020), which was attributed to lower relapse risk (adjusted HR, 0.46; p=0.014). These associations were also observed even within HLA-DRB1 allele-mismatched transplants in the standard stage group, indicating that EM might have impacts on relapse risk independently of allele mismatch. High HLA-DRB1 GVH-EM did not increase NRM in either stage.

CONCLUSIONS

High HLA-DRB1 GVH-EM may lead to potent GVT effects and favorable prognosis following CBT especially in the patients transplanted in the standard stage. This approach may facilitate appropriate unit selection and improve the overall prognosis of patients with hematological malignancies who receive CBT.

Biomarkers for predicting response to corticosteroid therapy for immune thrombocytopenic purpura

Patients with immune thrombocytopenic purpura (ITP) often receive corticosteroids as a first-line treatment strategy. The ability to predict the therapeutic response to corticosteroids before initiating treatment would reduce the risk of adverse events, but biomarkers of this parameter have not yet been established. Here, in a single-centre, retrospective, cohort study of 127 ITP patients who received corticosteroids as first-line treatment, we compared several characteristics and test results between those patients with a favourable response to corticosteroids (responder cohort, n = 68) and those with a poor response to corticosteroids (non-responder cohort, n = 59) to identify potential biomarkers that were predictive of corticosteroid response. We extracted six factors as indicative of poor response to corticosteroid therapy for ITP: old age (≥81 years) (odds ratio [OR], 2.44; p = 0.02); low platelet count (<9 × 10⁹ /L) (OR, 2.25; p = 0.02); high level of platelet-associated IgG (≥445 ng/10⁷ cells) (OR, 3.95; p < 0.01), high platelet distribution width (≥ 14.0 g/dL) (OR, 2.00; p = 0.03), high lymphocyte-to-monocyte ratio (≥ 3.52) (OR, 1.40, p = 0.04), and low megakaryocyte count in bone marrow (< 85.5/μl) (OR, 1.72; p = 0.04). Thus, our present data support the fact that these six factors are useful biomarkers for predicting corticosteroid response in patients with ITP.

Mild Acute Graft-Versus-Host Disease Improves Outcomes After HLA-Haploidentical-Related Donor Transplantation Using Posttransplant Cyclophosphamide and Cord Blood Transplantation

Haploidentical-related donor transplantation using posttransplant cyclophosphamide (PTCy-haplo) and cord blood transplantation (CBT) are valid alternatives for patients with hematological malignancies when HLA-matched donor transplantation (MDT) is unavailable. However, the effects of graft-versus-host disease (GVHD) on outcomes after these transplants have not been fully elucidated. Therefore, we evaluated the effects of acute and chronic GVHD on transplant outcomes after PTCy-haplo transplants and compared them with CBT and MDT. We included a total of 914 adult patients with hematological malignancies in the Kyoto Stem Cell Transplantation Group registry who received PTCy-haplo (N = 120), CBT (N = 402), and MDT (N = 392), and achieved neutrophil engraftment. A multivariate analysis revealed that grade I-II acute GVHD improved of overall survival (OS) after PTCy-haplo [hazard ratio (HR) = 0.39, P = 0.018] and CBT (HR = 0.48, P < 0.001), but not after MDT (HR = 0.80, P = 0.267) compared with patients without acute GVHD. Grade I-II acute GVHD had a trend toward reducing the risk of nonrelapse mortality (NRM) after PTCy-haplo (HR = 0.13, P = 0.060) and this positive effect was significant after CBT (HR = 0.39, P = 0.003). A negative impact of grade III-IV acute GVHD on NRM was observed after CBT and MDT, but not after PTCy-haplo. Limited chronic GVHD had a positive impact on OS after CBT and MDT, but not after PTCy-haplo. In conclusion, mild acute GVHD improved outcomes after PTCy-haplo and CBT, and limited chronic GVHD improved outcomes after CBT and MDT. These data indicated that the effects of GVHD on transplant outcomes depended on transplant platforms.

Single Cord Blood Transplantation Versus HLA-Haploidentical-related Donor Transplantation Using Posttransplant Cyclophosphamide in Patients With Hematological Malignancies

BACKGROUND

Unrelated cord blood (UCB) and haploidentical related donor transplantation using posttransplant cyclophosphamide (PTCy-haplo) have become alternative options to treat patients with hematological malignancies without a HLA-matched donor.

METHODS

We conducted a retrospective study using registry data from the Kyoto Stem Cell Transplantation Group for patients with hematological malignancies who received their first allogeneic hematopoietic cell transplantation using a single UCB unit (n = 460) or PTCy-haplo (N = 57) between 2013 and 2019.

RESULTS

We found that overall survival in the UCB group was comparable to that in the PTCy-haplo group (hazard ratio, 1.00; 95% confidence interval, 0.66-1.52), although neutrophil and platelet engraftment were significantly delayed. Nonrelapse mortality risk and the incidence of graft-versus-host disease in the UCB group were also comparable to those in the PTCy-haplo group. Although the relapse risk was similar between the UCB group and the PTCy-haplo group regardless of the disease risk, acute myeloid leukemia patients benefit from UCB transplant with a significantly lower relapse rate (hazard ratio, 0.38; 95% confidence interval, 0.18-0.76).

CONCLUSIONS

UCB transplant gives outcomes comparable to PTCy-haplo transplant, and both UCB and PTCy-haplo units are suitable as alternative donor sources for patients without an HLA-matched sibling or unrelated donor.

Coexistence of HLA and KIR ligand mismatches as a risk factor for viral infection early after cord blood transplantation

Viral infection is one of the lethal adverse events after cord blood transplantation (CBT). Human leukocyte antigen (HLA) and killer immunoglobulin-like receptor (KIR) ligand divergences can increase the risk of viral infection due to conflicting interactions between virus-infected cells and immune cells. However, the relationship between these disparities and the frequency of viral infection after CBT remains to be evaluated. Herein, we have conducted a retrospective multicenter study to assess the effect of HLA and KIR ligand mismatches on viral infections after CBT. The study included 429 patients, among which 126 viral infections occurred before day 100. Viral infection was significantly associated with poorer overall survival (OS; hazard ratio [HR] 1.74, p < 0.01). Patients harboring ≥3 mismatches in the HLA allele and inhibitory KIR ligand mismatches (HLA & KIR mismatches) had a significantly greater prevalence of viral infection (HR 1.66, p = 0.04). Thus, patients with HLA & KIR mismatches had poorer outcomes in terms of non-relapse mortality (HR 1.61, p = 0.05). Our study demonstrates the unfavorable impacts of HLA & KIR mismatches on viral infections and non-relapse mortality after CBT. Evaluating the viral infection risk and performance of an appropriate and early intervention in high-risk patients and optimizing the graft selection algorithm could improve the outcome of CBTs.

Dual effects of natural killer cells in transplantation for leukemia

Natural killer (NK) cells were originally considered to belong to the innate immune system to play a protective role against tumor cells and viral infections. In human, they can recognize self and non-self HLA class 1 as their ligand. So, analyzing the outcomes of allogeneic hematopoietic stem cell transplantation is a good opportunity to know the antitumor effects and regulatory effects of NK cells through HLA class 1 matching and mismatching of donor and recipient. In this review, I looked back on the main analysis results of the past transplants, summarized our reports consisting of many cases in a single ethnic, and showed that NK cells might work oppositely depending on the type of leukemia. New treatment strategies based on these concepts may offer individualized treatment options and ultimately increase offer the possibility of a cure for patients with leukemia.

Resistance of KIR Ligand-Missing Leukocytes to NK Cells In Vivo in Patients with Acquired Aplastic Anemia

The loss of killer cell Ig-like receptor ligands (KIR-Ls) due to the copy number-neutral loss of heterozygosity of chromosome 6p (6pLOH) in leukocytes of patients with acquired aplastic anemia (AA) may alter the susceptibility of the affected leukocytes to NK cell killing in vivo. We studied 408 AA patients, including 261 who were heterozygous for KIR-Ls, namely C1/C2 or Bw6/Bw4, for the presence of KIR-L-missing [KIR-L(-)] leukocytes. KIR-L(-) leukocytes were found in 14 (5.4%, C1 [n = 4], C2 [n = 3], and Bw4 [n = 7]) of the 261 patients, in whom corresponding KIR(+) licensed NK cells were detected. The incidence of 6pLOH in the 261 patients (18.0%) was comparable to that in 147 patients (13.6%) who were homozygous for KIR-L genes. The percentages of HLA-lacking granulocytes (0.8-50.3%, median 15.2%) in the total granulocytes of the patients with KIR-L(-) cells were significantly lower than those (1.2-99.4%, median 55.4%) in patients without KIR-L(-) cells. KIR2DS1 and KIR3DS1 were only possessed by three of the 14 patients, two of whom had C2/C2 leukocytes after losing C1 alleles. The expression of the KIR3DS1 ligand HLA-F was selectively lost on KIR-L(-) primitive hematopoietic stem cells derived from 6pLOH(+) induced pluripotent stem cells in one of the KIR3DS1(+) patients. These findings suggest that human NK cells are able to suppress the expansion of KIR-L(-) leukocytes but are unable to eliminate them partly due to the lack of activating KIRs on NK cells and the low HLA-F expression level on hematopoietic stem cells in AA patients.

Scoliosis, diabetes mellitus and total laminectomy at the 4th lumbar vertebra are independent risk factors for post-laminectomy fracture around the isthmus

OBJECTIVE

We aimed to identify the risk factors and clinical outcomes for post-laminectomy fracture around the isthmus, which can cause back pain or radiculopathy.

METHODS

We performed a retrospective cohort study involving all patients who underwent laminectomy splitting the spinous process for lumbar spinal stenosis between 2010 and 2014. The primary outcome measure was post-laminectomy fracture around the isthmus. Clinical outcomes were evaluated based on reoperation rate. To evaluate risk factors for fracture, the following parameters were collected: (1) patient characteristics and concomitant diabetes mellitus, (2) lumbar scoliosis and sagittal alignment parameters, and (3) surgical data, such as rate of total laminectomy. Logistic regression analysis was performed to identify the independent risk factors for post-laminectomy fracture.

RESULTS

Twelve of the 92 patients suffered a post-laminectomy fracture around the isthmus. Logistic regression analysis revealed that diabetes mellitus (odds ratio [OR]: 15.41; 95% confidence interval [CI]: 2.93-80.98; P=0.001), L4 total laminectomy (OR: 14.68; 95% CI: 1.51-142.76; P=0.021), and lumbar scoliosis (OR: 5.72; 95% CI: 1.16-28.21; P=0.032) were independent risk factors. The fracture group included 2 patients (16.7%) who required reoperation at the decompression level for recurrent leg pain, whereas the non-fracture group included 2 (2.5%) who underwent reoperation at a level different from the index procedure.

CONCLUSIONS

Post-laminectomy fractures around the isthmus were significantly associated with scoliosis, diabetes mellitus, and total laminectomy at L4. Total laminectomy at L4 is best avoided to reduce the risk of post-laminectomy fracture in patients with scoliosis or diabetes mellitus.

[Essential thrombocythemia correctly diagnosed through the guidance of comprehensive genomic profiling]

In 2003, a 60-year-old man presenting with thrombocytosis was referred to our hospital. Laboratory tests revealed normal white blood cell count and hemoglobin level. Bone marrow examination showed an increased number of megakaryocytes with dysplasia. G-banded karyotype analysis revealed del (5q). Initially, the patient was diagnosed with myelodysplastic/myeloproliferative neoplasm (MDS/MPN), and it was treated with aspirin and hydroxyurea. During the treatment course, fluorescence in situ hybridization for CSF1R and EGR1 was performed to detect del (5q), which showed negative results. In 2017, the patient had increased platelet count despite receiving treatment. A comprehensive genomic profiling revealed that the deleted region in this case was present in 5q14-5q23, which was different from the common deleted region of 5q- syndrome (5q32-5q33, where CSF1R was present) and that of high-risk MDS or acute myeloid leukemia (5q31, where EGR1 was present). Moreover, a CALR mutation was also detected. This case met the diagnostic criteria of essential thrombocythemia. The platelet count decreased with the administration of anagrelide. In conclusion, comprehensive genetic profiling is very important, and it leads to accurate diagnosis and therapy.

[MYC gene amplification attributed to double minutes in a patient with atypical chronic myeloid leukemia]

A 61-year-old man was admitted to our hospital with fever and massive leukocytosis. A bone marrow smear revealed an increased density of myeloid cells in various stages of maturation as well as dysplasia in the neutrophils. There was no proliferation of blasts, eosinophils, or basophils. Genomic analysis of the bone marrow cells revealed no detectable abnormalities associated with myeloproliferative neoplasms, including BCR-ABL1. Therefore, the patient was diagnosed with atypical chronic myeloid leukemia (aCML). Chromosomal analysis revealed the presence of 1-17 double minute chromosomes (dmin) in 20 of 20 tumor cells examined. Multiple MYC signals were detected via interphase fluorescence in situ hybridization, indicating MYC gene amplification in the dmins. Three months after the oral administration of hydroxyurea, leukocytosis reoccurred. Therefore, induction therapy followed with umbilical cord blood transplantation was performed. However, MYC signals remained detectable in the bone marrow sample obtained immediately after neutrophil engraftment, indicating the presence of residual tumor cells. To the best of our knowledge, this is the first case report of aCML with dmin gene amplification, suggesting that the dmin MYC amplification exacerbated the patient's disease.

Increased Relapse Risk of Acute Lymphoid Leukemia in Homozygous HLA-C1 Patients after HLA-Matched Allogeneic Transplantation: A Japanese National Registry Study

Natural killer (NK) cells expressing killer cell immunoglobulin-like receptors (KIRs) can recognize specific HLA class I molecules as their ligands. By studying a large Japanese transplant registry, we compared transplant outcomes between patients heterozygous for HLA-C^Asn80/C^Lys80 (HLA-C1/C2) and those homozygous for HLA-C1 (HLA-C1/C1) among patients who had undergone HLA-matched hematopoietic stem cell transplantation (HSCT). A high frequency of KIR2DL1 with strong HLA-C2 binding capacity and a low frequency of HLA-C2 and KIR haplotype B are characteristic of the Japanese population. In our previous report, HLA-C1/C1 patients with myeloid leukemia were less likely to relapse than HLA-C1/C2 patients. We newly assessed 2884 patients with acute lymphoblastic leukemia (ALL) who received HLA-matched allogeneic HSCT and analyzed their leukemia relapses by using adjusted competing-risk methods. HLA-C1/C1 patients with ALL experienced significantly higher relapse rates than HLA-C1/C2 patients (hazard ratio [HR] = 1.55, P = .003), contrary to our results in patients with myeloid leukemia. We allocated patients with ALL to several subgroups and found a higher frequency of relapse (HR >1.8) in the HLA-C1/C1 group than in the HLA-C1/C2 group among patients with Ph-negative ALL, those who had no cytomegalovirus reactivation, those who received transplants from donors who were aged 41 years or older, and those who experienced acute graft-versus-host disease, especially if it required systemic treatment. One interpretation of our results is that KIR2DL1-positive NK cells disrupt T cells, antigen-presenting cells, or both from working efficiently in transplant immunity in HLA-C1/C1 patients with ALL. Another is that KIR2DS1-positive NK cells directly attack HLA-C2-positive ALL blasts in HLA-C1/C2 patients. Whether HLA-C2 can cause recurrence to decrease or increase in patients depending on the disease (ALL or myeloid leukemia) will be a very important finding. We hope that our results will provide clues to the real mechanisms behind relapse after transplantation in patients with different HLA profiles.

Impact of Homozygous Conserved Extended HLA Haplotype on Single Cord Blood Transplantation: Lessons for Induced Pluripotent Stem Cell Banking and Transplantation in Allogeneic Settings

Induced pluripotent stem cells (iPSCs) have been applied to clinical regenerative cell therapy. Recently, an iPSC banking system to collect HLA haplotype (HP) homozygous (homo) cells for iPSC transplantation in allogeneic settings was proposed, and tissue transplantation generated from iPSC through banking has just began. We analyzed 5017 single cord blood transplantation (CBT) pairs with HLA-A, -B, -C, -DRB1 allele typing data and found 39 donor HLA homo donor to patient HLA heterozygous (hetero) pairs. Of note, all 39 HLA homo to hetero pairs engrafted neutrophils, except 1 early death pair, and all 30 assessable pairs engrafted platelets. Acute graft-versus-host disease (GVHD) grades II to IV and grades III to IV occurred in 17 and 3 of 38 assessable pairs, respectively. Competing risk regression analysis revealed a favorable risk of neutrophil engraftment and higher risk of acute GVHD compared with HLA-matched CBTs. Thirty-seven of 39 homo to hetero pairs had conserved extended HLA HPs (HP-1, n = 18; HP-2, n = 8; HP-3, n = 7; HP-4, n = 4; HP-5, n = 1) that were ethnicity-specific, and at least 1 of 2 patient HLA-A, -B, -C, and -DRB1 alleles in each locus were invariably shared with the same donor HP in 35 pairs. These findings confirmed our preliminary results with 6 HLA homo CBTs, and a trend of high incidence of acute GVHD was newly observed. Importantly, they imply the possibility that HLA-homo iPSC transplantation provides favorable engraftment and accordingly imply the merit of banking iPSC with homozygous major conserved extended HLA HPs.

Abstract P5-05-11: Clinical significance of androgen receptor expression in breast cancer

Background

Breast cancer is highly heterogeneous and immunohistochemistry (IHC) is used to determine breast cancer subtypes using estrogen and progesterone receptor (ER and PgR), HER2 and Ki-67. The androgen receptor (AR) is frequently expressed in breast cancer, but evaluation of AR has not been standardized and the oncogenic activity in breast cancer is still unclear. The objectives of this study were to assess the clinical significance of AR expression in breast cancer patients with primary (pretreatment and posttreatment) and recurrent breast cancer in relation to breast cancer subtype.

Methods

Primary and recurrent breast cancer patients who underwent treatment from March 2017 to May 2018 were enrolled in this study. A total of 591 primary breast cancer cases and 52 recurrent cases were analyzed. Thirty-four primary cases received treatment before surgery. The factors investigated included nodal status, tumor size, nuclear grade, ER/PgR and HER2 status, p53 overexpression, and the Ki-67 index value. The AR expression was evaluated using IHC and the expression was divided into 3 groups; negative, low (&lt;10%) and high (≥10%). Breast cancer subtypes were categorized based on the IHC data derived from ER/PgR, HER2 and Ki-67 (cutoff point: 20%) in invasive tumors.

Results

The AR expression rates were 69.7%(low: 33.9% and high: 35.8%)in all primary cases. Patients who received treatment before surgery had an AR rate of 38.2% which was significantly different from the untreated cases (p=0.002). In the cases with neoadjuvant chemotherapy, the positive rate significantly decreased after chemotherapy in the cases with non-pCR (pathological complete response). The positive rate of recurrent/metastatic cases was 57.7% (low: 34.6% and high: 23.1%). Higher AR expression significantly correlated with smaller tumor size, positive ER/PgR, lower Ki-67 values and nuclear grade and negative p53 overexpression. The AR expression rate was 72.5% in Luminal A, 73.2% in Luminal B, 80% in Luminal HER2, 56.8% in HER2 enriched and 43.5% in triple negative (TN) cases. Moreover, in the TN tumor cases, AR expression significantly correlated with postmenopausal status and a higher degree of malignancy determined by Ki-67, p53, and nuclear grade. However, there was no significant relationship between these factors and the other subtypes.

Conclusion

The AR expressions were higher in the primary breast cancer cases than in the pretreated and recurrent cases. The AR expression significantly correlated with a lower degree of malignancy and postmenopausal status only in the TN breast cancer cases. These findings suggest that the TN cases with AR-positive tumors have a more favorable prognosis compared with the cases with AR-negative tumors. However, further studies are needed to determine the predictive and prognostic factors for clinical use.

Citation Format: Arima N, Nishimura R, Osako T, Okumura Y, Nakano M, Fujisue M. Clinical significance of androgen receptor expression in 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 P5-05-11.

Abstract P2-09-32: Ki-67 index value and progesterone receptor status predict prognosis and suitable treatment in node-negative breast cancer patients with estrogen receptor positive and HER2 negative tumors

Background: Breast cancer is no longer a single disease with high molecular heterogeneity. Gene profiling has identified at least 4 subtypes: Luminal A, Luminal B, HER2-enriched and basal-like breast cancer. Moreover, immunohistochemistry (IHC) classification is now considered a surrogate for establishing breast cancer subtypes. In previous report Luminal A was defined as ER and PgR positive, HER2 negative, Ki-67 low and recurrence risk low based on the multi-gene-expression assay. The distinction between Luminal A-like and Luminal B-like can be made by either using a high Ki-67 value (≥20%) or a low PgR value (&lt; 20%). In this study, patients with ER positive, HER2 negative and negative node were classified into 4 groups according to the PgR and the Ki-67 status (cutoff points: 20%) and examined retrospectively in relation to clinicopathological findings including the recurrence score (RS) and disease-free survival (DFS).

Methods: A total of 1866 invasive breast cancer patients from November 2001 to November 2016 were included in this study. The cases were classified as follows; LA as high PgR/low Ki-67 (850 cases), LB1 as high PgR/high Ki-67 (553 cases), LB2 as low PgR/high Ki-67 (226 cases), and LB3 as low PgR/low Ki-67 (237 cases). Out of all these cases, 1510 were treated with endocrine therapy alone. The median follow-up period was 78.1 months. Moreover, 23 of the cases underwent a 21-gene expression assay and the RS (&lt; 25 and &gt; 26) was compared with our classification.

Results: The median age was 57.4 years (range: 25 - 94). T1 tumors were more common in the LA group and rare in the LB2 group. Nuclear grade 3 and p53 overexpression were significantly correlated with LB2. Endocrine therapy alone was performed in 87.4% (LA), 77.4% (LB1), 58.8% (LB2) and 86.9% (LB3), retrospectively. There were significant differences in DFS between the LA group (5y DFS: 98%, 10 y DFS: 95.9%) and the LB2 group (5y: 89.9%, 10y: 83.6%; p&lt;0.0001) or LB1 (5y: 94.9%, 10y: 89.5%; p&lt;0.0001), but there was no difference with the LB3 group (5y: 98.6%, 10y: 94.7%; p=0.88). In the cases with endocrine therapy alone, LA showed a similar DFS with LB3 (p=0.25). LB2 had a significantly worse DFS in all the cases and in the cases with endocrine therapy. Chemotherapy was administered to cases with a higher nuclear grade in combination with endocrine therapy. In the LB2 group, there was no difference in DFS between the cases with endocrine therapy and in the cases with chemo-endocrine therapy. Moreover, most of the cases with LA (1/1) and LB1 (15/16) had a RS of &lt;25, and all of the LB2 (6/6) cases had a RS of &gt;26.

Conclusion: The patients with LA and LB3 (both: Ki-67&lt;20%) had a favorable DFS even in the endocrine therapy alone group. However, LB1 and LB2 (both: Ki-67≥20%) had a poorer DFS. Moreover, LB2 (PgR&lt;20% and Ki-67≥20%) was significantly correlated with a higher degree of malignancy and benefited from chemotherapy. LA and LB3 with low Ki-67 values were considered to be a part of the Luminal A group. These data suggest that PgR and the Ki-67 status are useful in predicting prognosis and deciding the treatment strategy for patients with ER-positive and HER2 negative breast cancer.

Citation Format: Arima N, Nishimura R, Osako T, Nishiyama Y, Okumura Y, Fujisue M, Toyozumi Y. Ki-67 index value and progesterone receptor status predict prognosis and suitable treatment in node-negative breast cancer patients with estrogen receptor positive and HER2 negative tumors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-32.

Homozygous HLA-C1 is Associated with Reduced Risk of Relapse after HLA-Matched Transplantation in Patients with Myeloid Leukemia

Natural killer (NK) cells assume graft-versus-leukemia alloreactivity after hematopoietic stem cell transplantation (HSCT) through their inhibitory killer cell immunoglobulin-like receptors (KIRs). KIR2D family members recognize HLA-C alleles with Asn80 (HLA-C1) or Lys80 (HLA-C2). The predominance of HLA-C1 over HLA-C2 and the frequent presence of KIR2DL1 are characteristic of Japanese people. We compared clinical outcomes among homozygous HLA-C1 (HLA-C1/C1) patients and heterozygous HLA-C1/C2 patients who underwent HLA-matched HSCT for hematologic malignancies by assessing the data of 10,638 patients from the Japanese national registry. HLA-C1/C1 recipients had a lower rate of relapse than HLA-C1/C2 recipients after transplantation for acute myelogenous leukemia (AML) (hazard ratio [HR], .79; P = .006) and chronic myelogenous leukemia (CML) (HR, .48; P = .025), but not for acute lymphoblastic leukemia (HR, 1.36), lymphoma (HR, .97), or low-grade myelodysplastic syndrome (HR, 1.40). We then grouped AML and CML patients together and divided them into several subgroups. Advantages of HLA-C1/C1 recipients over HLA-C1/C2 recipients regarding relapse were observed irrespective of donor relation (related: HR, .79, P = .069; unrelated: HR, .77, P = .022), preparative regimen (myeloablative: HR, .79, P = .014; reduced intensity: HR, .73, P = .084), and occurrence of acute graft-versus-host disease (yes: HR, .70, P = .122; no, HR .71, P = .026) or cytomegalovirus reactivation (reactivated: HR .67,P = .054; nonreactivated: HR .71, P = .033); however, these advantages were not observed in recipients with a delay in achieving complete chimerism (HR, 1.06). The advantage of decreasing relapse and extending relapse-free survival of C1/1 over C1/2 KIR-ligand status was most pronounced in T cell-depleted HSCT (HR, .27; P < .001 and HR, .30; P = .002, respectively) and in children age <15 years (HR, .29; P < .001 and HR .31; P < .001, respectively). Our findings represent an important mechanism responsible for the immunity against HLA-C2-negative myeloid leukemia cells after HLA-matched transplantation.

Multiple Myeloma Presenting with Autoimmune Autonomic Ganglionopathy

Autoimmune autonomic ganglionopathy is an autonomic disorder that occurs as a symptom of paraneoplastic neurological syndrome. To date, there have been no reports on multiple myeloma with autoimmune autonomic ganglionopathy. A 37-year-old Japanese woman suffered from orthostatic hypotension was diagnosed with multiple myeloma (IgG kappa type), and a serological examination revealed the presence of anti-ganglionic nicotinic acetylcholine receptor (anti-gAChR) antibodies. She was treated for multiple myeloma, as a result, the autonomic disturbance improved and her anti-gAChR antibody titer decreased to undetectable levels, despite the fact that she only achieved a partial remission of multiple myeloma. Treatment for multiple myeloma may improve autoimmune autonomic ganglionopathy.

Dose-Modified Ifosfamide, Epirubicin, and Etoposide is a Safe and Effective Salvage Therapy with High Peripheral Blood Stem Cell Mobilization Capacity for Poorly Mobilized Hodgkin's Lymphoma and Non-Hodgkin's Lymphoma Patients

A dose modified ifosfamide, epirubicin, and etoposide (IVE) regimen was prospectively assessed for its efficacy in mobilizing peripheral blood stem cells for autologous transplantation. Two patients with Hodgkin's lymphoma and two with non-Hodgkin's lymphoma who were undergoing stem cell therapy were studied. All patients had a history of multiple treatments with insufficient stem cell mobilization. The dose modified IVE regimen consisted of ifosfamide 3 g/m(2) intravenously (IV) administered on days 1-2 in combination with epirubicin 50 mg/m(2) IV on day 1 and etoposide 200 mg/m(2) (100 mg/m(2) in two patients with complete remission) IV on days 1-3. The ifosfamide dosage was reduced to two-thirds of the original protocol. A substantial high yield of CD34(+) cells was achieved when patients were treated with a dose-modified IVE regimen, compared with that during the previous regimen (two with the ifosfamide, carboplatin, and etoposide [ICE] regimen, one with high-dose cyclophosphamide and one with the original IVE regimen). Two patients who had refractory and residual disease received a 200 mg/m(2) dose of etoposide, which resulted in tumor reduction (one patient with complete remission and one with further reduction in tumor size). After the IVE regimen, all four patients had a sufficient yield of CD34(+) cells in total, which was available for stem cell transplantation. Hematological and non-hematological toxicities were comparable in all regimens. This single-center prospective study demonstrated that the dose-modified IVE regimen can be used as a safe treatment with high mobilizing efficacy in heavily pretreated lymphoma patients.

Abstract P4-21-25: The importance of hormone receptor status on biomarker expression and the efficacy of lapatinib plus capecitabine therapy after progression on trastuzumab in HER2 positive recurrent and advanced breast cancer

Background: Anti-HER2 treatment using trastuzumab (Tmab) has contributed to improving the clinical outcome of HER2-positive breast cancerpatients. However, some patients do not respond to Tmab therapy and the combination of Lapatinib and capecitabine (LC) is an effective treatment option after progression on Tmab. Hormone receptor status is also an important factor for deciding if the patient should be treated with endocrine therapy as well. The aim of this study was to investigate the clinical significance of hormone receptor status in biomarker expression and to evaluate the efficacy of lapatinib therapy.

Materials and Methods: Eighty patients with HER2 positive breast cancer refractory to Tmab were enrolled in this prospective trial (KBC-SG 1107) between December 2011 and March 2014. The following treatment began after enrollment; lapatinib 1250-mg tablets were administered orally once daily and capecitabine (2000 mg/m2 per day) on days 1 to 14 every 21 days until disease progression or until severe adverse events. Total HER2 (H2T), p95HER2 (p95), and total HER3 (H3T) expression levels were quantified in formalin-fixed paraffin embedded samples using VeraTag assays. ER and progesterone receptor (PgR), PTEN and p95 expressions were evaluated using immunohistochemistry (IHC) and PIK3CA mutation using direct sequencing. Statistical analyses were performed using SPSS (ver. 21). A two-sided P&lt;0.05 was considered a statistically significant difference.

Results: The ER- and PgR-positive rates were 55.0% and 33.8%, respectively. The response rate to LC was 30% (CR: 1 case; PR: 23 cases), the clinical benefit rate was 51.3% and the median progression-free survival (PFS) was 174.5 days. Both ER and PgR negativity significantly correlated with higher H2T (cutoff: 13.8), p95HER2 (cutoff: 2.8) and PTEN expression levels (cutoff: H score of 100). Lower H2T expression levels and PIK3CA mutation rates were often observed in the non-responders (both: p=0.087). The ER and PgR status did not correlate with response. A high p95 and PTEN expression significantly correlated with longer PFS in ER and/or PgR positive cases (p=0.02 and 0.03), respectively. The overall survival (OS) after LC significantly correlated with the number of recurrence organs (p=0.0002) but not with the p95 and PTEN expression levels.

Conclusion: LC therapy was effective in Tmab-refractory HER2 positive breast cancer. Moreover, the biomarker expression differed depending on the ER/PgR status and a high p95 and PTEN expression correlated with longer PFS in ER and/or PgR positive cases. Further study is necessary to validate these findings.

Citation Format: Arima N, Nishimura R, Toh U, Tanaka M, Saimura M, Okumura Y, Saito T, Tanaka T, Teraoka M, Shimada K, Koga T, Kurashita K, Todoroki H, Ueo H, Ohi Y, Toyoshima S, Mitsuyama S, Tamura K. The importance of hormone receptor status on biomarker expression and the efficacy of lapatinib plus capecitabine therapy after progression on trastuzumab in HER2 positive recurrent and advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-25.

Abstract P6-07-05: PD-L1 expression and decreased tumor-infiltrating lymphocytes are associated with poor prognosis in patients with triple negative breast cancer

Background: Tumor microenvironment has been considered to have an active role in determining the aggressiveness of tumor cells. Recently, programmed cell death ligand-1 (PD-L1) expression or tumor-infiltrating lymphocytes (TILs) are known to be an important prognostic factor of breast cancer. However, the correlation of expression of PD-L1 and TILs still remains unclear. Triple-negative breast cancer (TNBC) is a heterogeneous tumor that encompasses many different subclasses. Further identification of these subclasses is necessary in order to predict prognosis and choose appropriate treatments. Our goal was to correlate PD-L1 expression with clinicopathological features including TILs by using a large cohort of TNBCs.

Patients and Methods: This study included 248 patients with primary TNBC who underwent resection without neoadjuvant chemotherapy at our three hospitals between January 2004 and December 2014. The tumor subtypes were routinely determined immunohistochemically by using resected specimens. IHC scoring for PD-L1 expression was defined in reference to that for HER2 expression. PD-L1 positivity was defined as both IHC 2+ and IHC 3+. Cases were defined as high if stromal TILs ≥50% according to recommendations by the International TILs Working Group.

Results: Of the 248 TNBCs, PD-L1 were expressed as positive in 103 (41.5%) tumors, and TILs were highly present in 118 (47.6%) tumors. PD-L1 expression was significantly correlated with higher levels of TILs (P &lt; 0.0001). There was no significant difference when the prognosis of the patients who had PD-L1-positive tumors was compared with that of the patients who had PD-L1-negative tumors (P = 0.56 in recurrence free survival [RFS] and P = 0.13 in overall survival [OS]). Meanwhile, the patients with high-TILs tumors had longer OS, compared to the patients with low-TILs tumors (P = 0.55 in RFS and P = 0.016 in OS). The analysis in the cross effect between PD-L1 expression and TILs using cox proportional hazards model demonstrated that the PD-L1 expression and TILs are not independent factors(P = 0.0018 in RFS and P = 0.015 in OS). The PD-L1-positive group with low-TILs had significantly shorter survival than the PD-L1-positive group with high-TILs (hazard ratio [HR] = 4.7, 95% confidence interval [CI] 1.6–12.7, P = 0.0067 in RFS; HR = 8.4, 95%CI 2.3-30.3, P = 0.0019 in OS).

Conclusions: Our data indicated that PD-L1 expression was related to higher levels of TILs, and PD-L1-positive tumors with low-TILs were associated with poor prognosis in patients with TNBCs. It is proposed that these biomarkers may be of use for predicting their prognosis and essential in the subclassification of TNBCs.

Citation Format: Mori H, Kubo M, Yamaguti R, Nishimura R, Osako T, Arima N, Okumura Y, Okido M, Yamada M, Kai M, Kishimoto J, Oda Y, Nakamura M. PD-L1 expression and decreased tumor-infiltrating lymphocytes are associated with poor prognosis in patients with triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-05.

Lifting of evacuation orders and subsequent efforts in Japan

With confirmation of the cold shutdown conditions of the nuclear reactors after the accident at Fukushima Daiichi nuclear power plant, the Japanese Government reclassified the areas under evacuation orders as follows: (1) difficult-to-return zones (>50 mSv y^-1), (2) restricted residence zones (20-50 mSv y^-1), and (3) zones in preparation for lifting of the evacuation order (<20 mSv y^-1). The Government continued its initiatives towards reconstruction of Fukushima, and has lifted evacuation orders in Zones 2 and 3. In terms of radiological protection, the Government emphasised its policy of placing importance on individual dose, and promoted the assignment of consultants in each municipality.

Principal component analysis uncovers cytomegalovirus-associated NK cell activation in Ph+ leukemia patients treated with dasatinib

Dasatinib treatment markedly increases the number of large granular lymphocytes (LGLs) in a proportion of Ph⁺ leukemia patients, which associates with a better prognosis. The lymphocytosis is predominantly observed in cytomegalovirus (CMV)-seropositive patients, yet detectable CMV reactivation exists only in a small fraction of patients. Thus, etiology of the lymphocytosis still remains unclear. Here, we identified NK cells as the dominant LGLs expanding in dasatinib-treated patients, and applied principal component analysis (PCA) to an extensive panel of NK cell markers to explore underlying factors in NK cell activation. PCA displayed phenotypic divergence of NK cells that reflects CMV-associated differentiation and genetic differences, and the divergence was markedly augmented in CMV-seropositive dasatinib-treated patients. Notably, the CMV-associated highly differentiated status of NK cells was already observed at leukemia diagnosis, and was further enhanced after starting dasatinib in virtually all CMV-seropositive patients. Thus, the extensive characterization of NK cells by PCA strongly suggests that CMV is an essential factor in the NK cell activation, which progresses stepwise during leukemia and subsequent dasatinib treatment most likely by subclinical CMV reactivation. This study provides a rationale for the exploitation of CMV-associated NK cell activation for treatment of leukemias.

[Therapy-Related Acute Myeloid Leukemia Following Etoposide Based Chemotherapy in Germ Cell Tumor]

A 27-year-old man visited our hospital with painless swelling of the left scrotum. Hematologic studies showed the following levels of lactate dehydrogenase, 3,171 IU/l ; alpha-fetoprotein, 2.2 ng/ml ; and β- human chorionic gonadotropin, 0.4 ng/ml, and abdominal computed tomography revealed a mass of 10×8 ×4 cm in the left testis, and that of 3.5×3.0×5.0 cm in the left renal hilar lymph node, without any other metastasis. Left high inguinal orchiectomy was performed, and histopathological examination revealed mixed form with seminoma and teratoma. He was diagnosed to have a left germ cell tumor with left renal hilar lymph node metastases, pT1, N3, M0, stage II C, indicating poor prognosis with IGCCC. The patient received four cycles of chemotherapy, COMPE regimen (CDDP, VCR, MTX, PEP, VP-16 [etoposide]). After lactate dehydrogenase, alpha-fetoprotein, and β -human chorionic gonadotropin all normalized, retroperitoneal lymph node dissection was performed. Histopathological examination revealed only a mature teratoma. Two and half years later, hematologic studies showed blast transformation. Bone marrow biopsy revealed acute myeloblastic lymphoma (M2). The patient received one cycle of AraC and daunorubicin, one cycle of high dose AraC, and three cycles of AraC and mitoxantrone. After chemotherapy, he has maintained a disease-free status for 11 years. In this case, etoposide, a topoisomerase II inhibitor, was the presumed cause of therapy-related acute myeloid leukemia. After administering chemotherapeutic agents especially etoposide, it is important to check blood count periodically for a long time.

Local recurrence risk after previous salvage mastectomy

INTRODUCTION

Breast-conserving surgery is a standard treatment for early breast cancer. For ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery, salvage mastectomy is the current standard surgical procedure. However, it is not rare for patients with IBTR who have received salvage mastectomy to develop local recurrence. In this study, we examined the risk factors of local recurrence after salvage mastectomy for IBTR.

PATIENTS AND METHODS

A total of 118 consecutive patients who had histologically confirmed IBTR without distant metastases and underwent salvage mastectomy without irradiation for IBTR between 1989 and 2008 were included from eight institutions in Japan. The risk factors of local recurrence were assessed.

RESULTS

The median follow-up period from salvage mastectomy for IBTR was 4.6 years. Patients with pN2 or higher on diagnosis of the primary tumor showed significantly poorer local recurrence-free survival than those with pN0 or pN1 at primary tumor (p < 0.001). Multivariate analysis showed that the lymph node status of the primary tumor was a significantly independent predictive factor of local recurrence-free survival (p = 0.02).

CONCLUSION

The lymph node status of the primary tumor might be a predictive factor of local recurrence-free survival after salvage mastectomy for IBTR. Further research and validation studies are needed. (UMIN-CTR number UMIN000008136).

Abstract P4-09-15: BRCAness and PD-L1 expression of basal-like and not basal-like triple negative breast cancer

Background: Triple Negative Breast Cancer (TNBC) subtype occurs in approximately 20% of all patients with breast cancer and is associated with rapid growth, early metastasis and poor prognosis compared with other subtypes. TNBCs are a heterogeneous disease entity and further subclassification is needed, but still ongoing. In this study, we assessed BRCAness, defined as shared characteristics between sporadic and BRCA1-mutated tumors, in a cohort of basal-like and non-basal-like TNBCs.

Patients and Methods: DNA was isolated from formalin-fixed paraffin-embedded tumor tissues and BRCAness status was analyzed in 262 patients with primary TNBCs resected at our three hospitals between 2004 and 2014. Classification of BRCAness was performed by using Multiple Ligation-dependent Probe Amplification (MLPA) with the probemix P376 BRCA1ness by MRC (Amsterdam, Holland). The tumor subtypes were routinely determined immunohistochemically by using resected specimens. Basal-like phenotype was defined as being positive for Epidermal Growth Factor Receptor (EGFR) and/or Cytokeratin 5/6 (CK5/6). Moreover, TNBCs were stained and analyzed for programmed cell death ligand-1 (PD-L1) expression as a target of new immune therapies.

Results: Of 262 TNBCs, 232 tumors (88.5%) was a basal-like phenotype. The results of MLPA assay showed that 159 (68.5%) of 232 tumors had a BRCAness profile. Patients with basal-like BRCAness tumors were younger than patients with basal-like non-BRCAness tumors (p&lt;0.0001). There was no significant difference between the two groups regarding pathological stage. The basal-like BRCAness group had shorter relapse-free survival (RFS) and overall survival (OS) than the basal-like non-BRCAness group (p=0.028 and p=0.13, respectively), and anthracycline-based regimens provided greater benefit to the basal-like BRCAness group significantly (p=0.01 in RFS and p=0.007 in OS). PD-L1 was expressed in 71 (44.7%) of 159 basal-like TNBCs with BRCAness.

Conclusion: We reported the majority of basal-like TNBCs showed a BRCAness profile and PD-L1 expressed in approximately 50% of BRCAness tumors. It is known that about 30% of BRCAness tumors are BRCA1-mutated tumors. Those biomarkers are essential for subclassification of TNBCs and may offer not only platinum-based chemotherapy but also novel therapies, such as immune-targeted therapies of PD-1/PD-L1 inhibitors and PARP inhibitors, to patients with basal-like TNBCs with BRCAness.

Citation Format: Mori H, Kubo M, Yamada M, Kai M, Osako T, Nishimura R, Arima N, Okido M, Kuroki S, Oda Y, Nakamura M. BRCAness and PD-L1 expression of basal-like and not basal-like triple negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-15.

Abstract P4-09-26: The difference between metachronous and synchronous bilateral breast cancer in terms of clinical features and biology

Introduction

The recent diagnostic modality such as MRI can diagnose a tiny breast lesion even in healthy contralateral breasts. Recently, the rate of contralateral prophylactic mastectomy (CPM) is on the rise in the United States. In Japan, the CPM has been started for selected patients with a high risk. In this study, we divided bilateral breast cancers into the synchronous and the metachronous group and then compared the clinical features and biology.

Patients and Methods

Out of 216 bilateral breast cancer patients who underwent surgery between 1995 and March 2015, there were 101 synchronous breast cancer cases and 115 metachronous breast cancer cases (interval to the second tumor &gt; 1 year). The items examined were age, tumor size, lymph nodal status, histological type, and biological markers (ER, PgR, HER2, p53 and Ki-67 index values) in the cases with paired data.

Results

1. The incidence of metachronous tumors was relatively stable at 2.1–2.7% throughout the period. On the other hand, the incidence of synchronous tumors has increased to 4.4% in the most recent 5-year period and the median interval was 7.1 years.

2. There was no difference in the tumor size of both tumors in the synchronous group, but the second tumor was significantly smaller than the first tumor in the metachronous group (2.2cm to 1.7cm). The node negative rates showed no difference between two groups.

3. The cases with DCIS were seen in 20% and 25% of the synchronous group and 12% and 16% of the metachronous group. Most of the patients (94.3%) with invasive cancer received systemic adjuvant therapy in the metachronous group.

4. The ER positive rates of both tumors were 87.1% and 88.1% in the synchronous group and 71.6% and 68.4% in the metachronous group, respectively. The concordance rates were higher in the synchronous group (p=0.02). Moreover, there was a significant difference in ER positive rates between the two groups (p=0.01) and the ER negative tumors were more frequent in the second tumor of the metachronous group. The PgR negative tumors increased in the second tumor of metachronous cases. The shorter the interval (&lt; 5years), the more the ER positive rate decreased (p=0.002). However, the longer interval did not correlate with the change of receptor status.

5. The Ki-67 index values significantly increased in the second tumor of the metachronous group, especially in the cases with a shorter interval. However, there was no difference in the synchronous group. The p53 overexpression rates significantly increased in the cases with a shorter interval.

6. The postoperative prognosis for the first tumor did not differ in both groups.

Conclusion

The incidence of synchronous bilateral breast cancer cases have increased but have remained relatively stable in the metachronous group. The concordance rates of the ER, PgR, Ki-67 and p53 status were higher in the synchronous group but the cases with negative ER, negative PgR, higher Ki-67 values and positive p53 increased in the second tumor of the metachronous group. These findings suggest that adjuvant systemic therapy played a important role in the treatment of bilateral breast cancer but the secondary tumor was more aggressive in the metachronous cases.

Citation Format: Arima N, Nishimura R, Osako T, Nishiyama Y, Fujisue M, Okumura Y, Murakami K, Toyozumi Y. The difference between metachronous and synchronous bilateral breast cancer in terms of clinical features and biology. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-26.

Pregnancy outcomes of patients with paroxysmal nocturnal hemoglobinuria treated with eculizumab: a Japanese experience and updated review

Pregnancy with paroxysmal nocturnal hemoglobinuria (PNH) is associated with significant risk of complications, such as life-threatening thrombosis. Recently, eculizumab has come into clinical use and revolutionized the treatment of PNH. However, clinical information regarding eculizumab use for PNH during pregnancy is limited. The present report describes pregnancies with PNH treated with eculizumab that were registered with the Japan PNH study group and reviews the literature. In case 1, the patient received eculizumab throughout pregnancy and delivered a healthy neonate at term, although breakthrough hemolysis occurred at 20 weeks of gestation. In case 2, the patient discontinued eculizumab before pregnancy and developed preeclampsia at 27 weeks of gestation. She received eculizumab and delivered a preterm, but healthy, neonate by cesarean section. In case 3, the patient received eculizumab from 18 weeks of gestation and delivered a healthy neonate at term without any complications. Reports of 11 pregnant women treated with eculizumab were identified in the literature. Of 14 pregnancies, including our own cases, breakthrough hemolysis and preeclampsia occurred in five and two cases, respectively. There were no thrombotic complications, maternal or neonatal deaths, or fetal structural abnormalities. Thus, eculizumab appears to be safe and effective for managing PNH during pregnancy.

Clinical features of Japanese polycythemia vera and essential thrombocythemia patients harboring CALR, JAK2V617F, JAK2Ex12del, and MPLW515L/K mutations

The risk of complication of polycythemia vera (PV) and essential thrombocythemia (ET) by thrombosis in Japanese patients is clearly lower than in western populations, suggesting that genetic background such as race may influence the clinical features. This study aimed to clarify the relationship between genetic mutations and haplotypes and clinical features in Japanese patients with PV and ET. Clinical features were assessed prospectively among 74 PV and 303 ET patients. There were no clinical differences, including JAK2V617F allele burden, between PV patients harboring the various genetic mutations. However, CALR mutation-positive ET patients had a significantly lower WBC count, Hb value, Ht value, and neutrophil alkaline phosphatase score (NAP), and significantly more platelets, relative to JAK2V617F-positive ET patients and ET patients with no mutations. Compared to normal controls, the frequency of the JAK246/1 haplotype was significantly higher among patients with JAK2V617F, JAK2Ex12del, or MPL mutations, whereas no significant difference was found among CALR mutation-positive patients. CALR mutation-positive patients had a lower incidence of thrombosis relative to JAK2V617F-positive patients. Our findings suggest that JAK2V617F-positive ET patients and CALR mutation-positive patients have different mechanisms of occurrence and clinical features of ET, suggesting the potential need for therapy stratification in the future.

Influence of Differently Licensed KIR2DL1-Positive Natural Killer Cells in Transplant Recipients with Acute Leukemia: A Japanese National Registry Study

Licensing by self MHC class I ligands is required for proper natural killer (NK) cell response. NK cells with inhibitory killer cell immunoglobulin-like receptors for nonself MHC exhibit transient alloreactivity after hematopoietic stem cell transplantation (HSCT). We analyzed 3866 recipients in the Japan national registry who underwent their first allogeneic HSCT for acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) from HLA-A, -B, and -DRB1 allele-genomatched unrelated donors. By classifying them into 5 independent groups based on HLA-C group matching and assumed donor NK cell status, we found that for HLA-C-matched HSCT for AML in HLA-C1/C1 recipients, in whom transient alloreactivity against HLA-C2-negative leukemic cells was expected, the relapse rate was significantly lower than it was in HLA-C-matched HSCT for AML in HLA-C1/C2 recipients (hazard ratio [HR], .72; P = .011). This difference was not observed in HLA-C-matched HSCT for ALL. Compared with HLA-C-matched HSCT, significantly higher mortality was observed in HLA-C1/C1 AML patients who received transplants from HLA-C-mismatched HLA-C1/C1 donors (HR, 1.37; P = .001) and in HLA-C1/C1 ALL patients who received transplants from HLA-C2-positive donors (HR, 2.13; P = .005). In conclusion, donor selection based on leukemic subtype and donor HLA-C group matching improves transplantation outcome after HLA-C-mismatched HSCT.

Change in estrogen receptor, HER2, and Ki-67 status between primary breast cancer and ipsilateral breast cancer tumor recurrence

INTRODUCTION

Changes in the biological marker status between primary and recurrent tumors are observed in breast cancer. However, their clinical significance is still uncertain, especially for patients with ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery.

PATIENTS AND METHODS

A total of 117 patients with IBTR without distant metastases were enrolled in this study. All patients were examined for estrogen receptor (ER), HER2, and Ki-67 in both the primary tumors and paired IBTR. We evaluated the impact of changes in these biomarkers between primary tumors and IBTR on the prognosis after IBTR.

RESULTS

There were no associations of changes in the ER, HER2 status with distant disease-free survival (DDFS) after surgical resection of IBTR, whereas the change in the Ki-67 status between the primary tumors and IBTR was significantly correlated with DDFS (unadjusted: p = 0.0094; adjusted: p = 0.013). Patients in the "increased or remained high" Ki-67 group had a significantly shorter DDFS than those in the "decreased or remained low" Ki-67 group (5-year DDFS: 55.5 vs. 79.3%, respectively, p = 0.0084 by log-rank test).

CONCLUSION

An increased or persistently high Ki-67 status in the IBTR was significantly correlated with a poorer prognosis after IBTR.

Prognostic impact of preoperative monocyte counts in patients with resected lung adenocarcinoma

OBJECTIVES

Increasing evidence suggests that an elevated peripheral monocyte count at presentation predicts a poor prognosis in various types of malignancy, including malignant lymphoma. In lung adenocarcinoma, tumor-associated macrophages (TAMs) were reported to be associated with a poor prognosis. However, it is unknown if an elevated peripheral monocyte count is associated with a poor prognosis in lung adenocarcinoma. This study assessed the prognostic impact of the preoperative peripheral monocyte count in lung adenocarcinoma.

MATERIALS AND METHODS

We retrospectively analyzed 302 consecutive patients with lung adenocarcinoma who received curative resection at Kitano Hospital. The receiver operating characteristic (ROC) curve for the peripheral monocyte count was used to determine the cut-off value. The relations between peripheral monocyte counts and clinicopathological factors were assessed. We also evaluated the impacts of possible prognostic factors including the preoperative peripheral monocyte count on survival, using the two-tailed log-rank test and Cox proportional hazards model. In addition, immunohistochemical staining for CD68 was performed to evaluate the monocytes in primary tumors.

RESULTS

A peripheral monocyte count of 430mm(-3) was the optimal cut-off value for prognosis. An elevated peripheral monocyte count was significantly associated with sex, performance status, smoking history, chronic obstructive pulmonary disease and interstitial lung disease. The two-tailed log-rank test demonstrated that patients with an elevated peripheral monocyte count experienced a poorer recurrence-free survival (RFS) and overall survival (OS) (P=0.0063, P<0.0001, respectively). In the multivariate analysis an elevated peripheral monocyte count was shown to be an independent prognostic factor for the RFS and OS (HR: 1.765; 95% CI: 1.071-2.910; P=0.0258, HR: 4.339; 95% CI: 2.032-9.263; P=0.0001, respectively). Furthermore, numbers of the monocytes in primary tumors significantly correlated with peripheral monocyte counts (r=0.627, P<0.0001).

CONCLUSION

The preoperative peripheral monocyte count is an important prognostic factor for patients with lung adenocarcinoma after curative resection.

Ratio of peripheral blood absolute lymphocyte count to absolute monocyte count at diagnosis is associated with progression-free survival in follicular lymphoma

The prognosis of follicular lymphoma (FL) is significantly associated with host immunity and tumor microenvironment. Lymphopenia has been identified as a negative prognostic factor for FL. The association between monocytosis and progression-free survival (PFS) in FL remains controversial. It is unknown whether the ratio of peripheral blood absolute lymphocyte count to absolute monocyte count (ALC/AMC) at diagnosis is associated with FL prognosis. We studied 99 consecutive patients with FL who were treated with rituximab-containing chemotherapy at Kitano Hospital or Kyoto University Hospital between 2000 and 2012. We analyzed individual variables associated with the ALC/AMC ratio before treatment, as well as known prognostic factors of FL, and found that an ALC/AMC ratio of 4.7 was the best cut-off value for PFS. Kaplan-Meier analysis showed that a decreased ALC/AMC ratio was associated with inferior PFS (P = 0.022). Multivariate analysis showed that a decreased ALC/AMC ratio was a significant poor prognostic factor independent of other variables (hazard ratio, 2.714; 95 % confidence interval, 1.060-6.948; P = 0.037). The ALC/AMC ratio before treatment may be a significant prognostic factor predicting PFS of FL.

Abstract P6-05-14: Prognostic significance of Ki-67 index value at primary breast tumor in recurrent breast cancer

Introduction: The Ki-67 index value is a prognostic factor in primary breast cancer and is a proliferation marker that also distinguishes between luminal type A and type B breast cancer. Moreover, change in Ki-67 index value due to treatment and recurrence is considered to be important in treating breast cancer. The evaluative procedure in this study was on two levels; first, we examined whether the baseline Ki-67 value at the primary tumor is useful as a prognostic factor after recurrence, and second, we looked at the changes in the values after recurrence.

Patients and Methods: Immunohistochemical (IHC) analysis of the Ki-67 index was performed on 4701 patients with primary breast cancer from 1987 until March 2013 at Kumamoto City Hospital. Out of these patients, there were 666 consecutive cases with recurrence after primary surgery. The fraction of proliferating cells (positive for Ki-67) was based on a count of at least 500 tumor cells in the area including the hot spot, and the Ki-67 values were divided into 2 or 3 groups; &lt;20% and ≥20% (and ≥50%). Items examined were ER, PgR, HER2, tumor size, nodal status at primary tumor, and recurrent site (soft tissue, bone and viscera) and disease-free interval (DFI). Cox's proportional hazard model was used to perform a univariate and multivariate analyses of the factors related to overall survival (OS) after recurrence. The median follow-up period was 65.9 months in the remaining survival group. In 101 recurrent cases from whom the recurrent lesion was resected, the change in biological markers (Ki-67, ER and PgR) were evaluated.

Results: The median Ki-67 value at baseline was 20% in all the cases and 27% in the recurrent cases. In terms of recurrent site, the values were low (23%) in patients with bone metastasis, whereas patients with liver or brain metastasis showed higher values (38% and 53%, respectively). Moreover, DFI was inversely correlated with Ki-67 values. Univariate and multivariate analyses were performed to identify the prognostic factors for OS after recurrence. The significant factors included tumor size, lymph node status, ER, PgR, DFI, recurrent site, and the Ki-67 index value. Among these factors, a multivariate analysis revealed that the Ki-67 index value at primary tumor was an independent significant factor. The hormone receptor positive rate from the primary tumor to recurrence decreased from 67.3% to 63.4% and 64.4% to 50% for ER and PgR, respectively. The Ki-67 index value increased significantly from a mean of 28.9% at primary tumor to 35.7% at relapse. Furthermore, the Ki-67 index value at primary tumor was a significant prognostic factor for OS after recurrence in this cohort.

Conclusion: The Ki-67 value at primary tumor was a significant prognostic factor for OS after recurrence. The Ki-67 index value increased significantly after recurrence. It is therefore important to take the Ki-67 index into consideration in the treatment and follow-up of breast cancer patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-14.

Abstract P5-05-06: Menopausal status: An important consideration in determining the biology and prognosis of estrogen receptor-positive and progesterone receptor-negative breast cancer

Background: Transcription of the progesterone receptor (PgR) gene is regulated by estrogen in the breast tissue. PgR loss is considered to be a result in the reduction of estrogen receptor (ER) activity, due to either low circulating estrogen in some older women or a high growth factor signaling. Among the ER-positive breast cancer patients, PR-negative cases frequently have a higher resistance to endocrine therapy, and have a poorer prognosis. Therefore, we examined the clinical significance of ER+/PgR- tumors in luminal/HER2 negative breast cancer and its relationship to menopausal status.

Methods: The sample for this study came from 1791 consecutive patients with HER2 negative primary breast cancer from January 2002 to March 2013. The ER and PgR expressions were evaluated using immunohistochemistry (IHC). 1586cases had ER+/PgR+ tumor, 205cases had ER+/PgR- tumor. The items examined were nuclear grade, Ki-67 index value, TP53, tumor size and number of lymph node involvement. The Ki-67 index value and TP53 were evaluated using IHC and the cut-off values were 20% and 50%, respectively. Recurrence free survival (RFS) and breast cancer-specific survival (BCSS) was calculated using the Kaplan-Meier method and evaluated by the log-rank test or generalized Wicoxon test in stage 1 and 2 breast cancer.

Results: In terms of the distribution of ER and PgR status, ER+/PgR- were frequently seen in postmenopausal patients (13.7% vs 6.8%, respectively). Patients with ER+/PgR-and HER2 negative tumors had significantly smaller tumors, lower Ki-67 values, and a lower nuclear grade in the postmenopausal group compared with those in the premenopausal group. Moreover, RFS trended to be better in the postmenopausal group (p = 0.06), but there was no significant difference. BCSS was significantly higher in the postmenopausal cases (p = 0.001). On the other hand, in patients with ER+/PgR+ tumors, there was no significant difference in RFS and BCSS between the post- and pre-menopausal groups.

Conclusion: The ER+/PgR- tumors were more commonly seen in postmenopausal patients. The biological characteristics of ER+/PgR- tumors were significantly different in terms of the Ki-67 index value, nuclear grade, and the prognosis (BCSS and RFS) between pre- and postmenopausal status. Moreover, the postmenopausal group had a more favorable biology and prognosis than the premenopausal group. Therefore, the findings in this study indicate that menopausal status is related to the biology and prognosis in patients with ER+/PgR- tumors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-05-06.

Abstract P1-02-01: Pre-analytical setting is critical for an assessment of the Ki-67 labeling index for breast cancer

Background: The Ki-67 labeling index (LI) is useful in determining the efficacy of chemotherapy for patients with ER-positive and HER2-negative breast cancer. However, standardization of Ki-67 assessment has not yet been established. In terms of the factors that may affect Ki-67 LI, recent studies have focused on inter-observer variability in the interpretation of these values and insufficient attention has been given to the importance of handling the tissue. Therefore, this study focused on the effect of tissue fixation on Ki-67 LI.

Methods:

The effects of several pre-analytical conditions on the Ki-67 LI were studied as follows;

(1) Type of fixation: Each 173 surgically excised tumors were fixed with either 10% neutral buffered formalin or 15% formalin on the same condition, followed by assessment of Ki-67 LI.

(2) Time of fixation: Each study was repeated more than three times to confirm the result.

A: Time to fixation: A part of tumor, sliced from the surgically excised tumor, was kept in 4° for several hours to overnight before formalin fixation. Ki-67 LI was compared between the tumor with immediate and delayed fixation.

B: Time of fixation:

Insufficient fixation: A part of tumor, sliced from the surgically excised tumor, was fixed with formalin for 3 hours, followed by preparation of a paraffin-embedded block. Ki-67 LI was compared between the tumor with proper and shorter fixation.

Prolonged fixation: Some pieces of slice were prepared from the surgically excised tumor, followed by each preparation of a paraffin-embedded block at a designated fixation period. Ki-67 LI was compared among each sample fixed in a different period of time.

(3) Surgically excised tumors on Ki-67 LI:

A: Effect of cutting onto the tumor before fixation: Ki-67 LI in each 595 surgically excised tumor with or without cutting onto the tumor before fixation, was analyzed.

B: Comparison between core needle biopsy and surgically excised tissue: Ki-67 LI in each 136 pairs of core needle biopsy and surgically excised tissue originated from the same tumor was compared.

Results:

(1) Ki-67 LI was significantly higher when 10% neutral buffered formalin was used as a fixative compared to 15% formalin (p = 0.018).

(2) Ki-67 LI was reduced in some degree when time to fixation was delayed, while insufficient fixation caused dramatic reduction of Ki-67 LI compared to that seen in an either ER or HER2. A prolonged period of fixation caused gradual reduction of Ki-67 LI associated with diminished nuclear labeling.

(3) Ki-67 LI was significantly higher in the tumor cut onto before fixation (p = 0.018). There was no significant difference in Ki-67 LI between core needle and surgically excised specimens (p = 0.107), when the tumor was properly fixed.

Conclusion: Our results suggest that pre-analytical setting critically influences the Ki-67 labeling. In order to standardize Ki-67 LI assessment in breast cancer, the care in handling of the pre-analytical tissue is crucial in determining accurate Ki-67 values.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-02-01.