Evaluating the addition of bevacizumab to endocrine therapy as first-line treatment for hormone receptor-positive metastatic breast cancer: a pooled analysis from the LEA (GEICAM/2006-11_GBG51) and CALGB 40503 (Alliance) trials

BACKGROUND

Randomised trials comparing the efficacy of standard endocrine therapy (ET) versus experimental ET + bevacizumab (Bev) in 1st line hormone receptor-positive patients with metastatic breast cancer have thus far shown conflicting results.

PATIENTS AND METHODS

We pooled data from two similar phase III randomised trials of ET ± Bev (LEA and Cancer and Leukemia Group B 40503) to increase precision in estimating treatment effect. Primary end-point was progression-free survival (PFS). Secondary end-points were overall survival (OS), objective response rate (ORR), clinical benefit rate (CBR) and safety. Exploratory analyses were performed within subgroups defined by patients with recurrent disease, de novo disease, prior endocrine sensitivity or resistance and reported grades III-IV hypertension and proteinuria.

RESULTS

The pooled sample consisted of 749 patients randomised to ET or ET + Bev. Median PFS was 14.3 months for ET versus 19 months for ET + Bev (unadjusted hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.66-0.91; p < 0.01). ORR and CBR with ET and ET + Bev were 40 versus 61% (p < 0.01) and 64 versus 77% (p < 0.01), respectively. There was no difference in OS (HR 0.96; 95% CI 0.77-1.18; p = 0.68). PFS was superior for ET + Bev for endocrine-sensitive patients (HR 0.68; 95% CI 0.53-0.89; p = 0.004). Grade III-IV hypertension (2.2 versus 20.1%), proteinuria (0 versus 9.3%), cardiovascular (0.5 versus 4.2%) and liver events (0 versus 2.9%) were significantly higher for ET + Bev (all p < 0.01). Hypertension and proteinuria were not predictors of efficacy (interaction test p = 0.33).

CONCLUSION

The addition of Bev to ET increased PFS overall and in endocrine-sensitive patients but not OS at the expense of significant additional toxicity.

TRIALS REGISTRATION

ClinicalTrial.Gov NCT00545077 and NCT00601900.

Abstract PD1-03: Multivariate analysis of subtype and gene expression signatures predictive of pathologic complete response (pCR) in triple-negative breast cancer (TNBC): CALGB 40603 (Alliance)

Support: U10CA180821, U10CA180882

Background: The addition of either carboplatin (Cb) or bevacizumab (Bev) to standard neoadjuvant chemotherapy (NACT) increases pCR rates in TNBC overall and in the dominant subset of basal-like cancers (Sikov et al, JCO 2015; Sikov et al, SABCS 2014). Multigene expression signatures more accurately reflect tumor biology for response prediction and prognosis than individual gene expression. We evaluated the ability of multivariate analysis of gene expression signatures to create predictive models for achievement of pCR in TNBC.

Methods: RNA sequencing was successful on 389 pretreatment samples from patients with available pCR data, and used to assign PAM50 subtype and calculate gene signatures scores for 489 published expression signatures. Elastic net, a penalized regression model for high dimensional variable selection, was used to select features associated with pCR in all TNBC and in the basal-like subset. Models were derived in a training set (2/3 of samples) and validated in a separate test set (1/3). A separate model was derived using 196 TNBC samples from patients treated only on the standard NACT +/- Cb arms for application to external TNBC neoadjuvant data sets not treated with Bev.

Results: Consistent with our prior partial data set, 343 (88%) of the cancers were classified basal-like, in whom the in breast pCR rate was 54%; the remainder were classified normal-like (n=32) or HER2-enriched (n=14) with a non-basal pCR rate of 56%. Elastic Net analysis in all TNBC generated a model of 23 signatures and treatment assignment with 68% sensitivity and 64% specificity. The area under the curve was 0.64 (p-value=0.0019). Nineteen modules, including immune cell signatures (Th1, NK, IgG), immunoglobulin variable region expression, addition of Cb and Bev and expression of genes at regions 15q25, 17p11.2-13.3, and 8p22 were positively associated with response. The latter two regions are associated with aggressive breast cancer, and while not part of the 17p13 signature, this region contains TP53, a gene important in TNBC. Six modules were associated with resistance, including luminal progenitor, TGFB, NOTCH, FOS/JUN, 8p amplicon, and eosinophil signatures. When limited to basal-like samples, a model including 32 modules and addition of Cb and Bev was generated, with 62.3% sensitivity and 59.1% specificity. Seventeen features were selected in both models. Omitting Bev-treated patients, a model using just the gene expression signatures was developed. The predictive value of this model will be assessed using an external cohort of TNBC patients treated with neoadjuvant docetaxel and Cb (NCT01560663) and results presented.

Conclusions: Multivariate analysis of gene expression signatures derived from pretreatment samples enabled the construction of models to predict achievement of pCR in TNBC. These models performed well on our test set, and will be assessed for their predictive ability in other TNBC data sets. If validated by future analyses, this could help us identify patients likely to achieve pCR with standard NACT and may benefit from the addition of agents such as Cb or Bev.

ClinicalTrials.gov Identifier: NCT00861705.

Citation Format: Hoadley KA, Hyslop T, Fan C, Berry DA, Hahn O, Tolaney SM, Sikov WM, Perou CM, Carey LA. Multivariate analysis of subtype and gene expression signatures predictive of pathologic complete response (pCR) in triple-negative breast cancer (TNBC): CALGB 40603 (Alliance) [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 PD1-03.

A Novel Approach to Visualizing Dark Matter Simulations

In the last decades cosmological N-body dark matter simulations have enabled ab initio studies of the formation of structure in the Universe. Gravity amplified small density fluctuations generated shortly after the Big Bang, leading to the formation of galaxies in the cosmic web. These calculations have led to a growing demand for methods to analyze time-dependent particle based simulations. Rendering methods for such N-body simulation data usually employ some kind of splatting approach via point based rendering primitives and approximate the spatial distributions of physical quantities using kernel interpolation techniques, common in SPH (Smoothed Particle Hydrodynamics)-codes. This paper proposes three GPU-assisted rendering approaches, based on a new, more accurate method to compute the physical densities of dark matter simulation data. It uses full phase-space information to generate a tetrahedral tessellation of the computational domain, with mesh vertices defined by the simulation's dark matter particle positions. Over time the mesh is deformed by gravitational forces, causing the tetrahedral cells to warp and overlap. The new methods are well suited to visualize the cosmic web. In particular they preserve caustics, regions of high density that emerge, when several streams of dark matter particles share the same location in space, indicating the formation of structures like sheets, filaments and halos. We demonstrate the superior image quality of the new approaches in a comparison with three standard rendering techniques for N-body simulation data.

Phase I study of preoperative chemoradiation therapy in unresectable locally advanced breast cancer (LABC)

11097

Introduction: Therapy of unresectable LABC is challenging due to the need to resect local disease and prevent distant metastases. We conducted a phase I trial to determine the maximum tolerated dose of preoperative vinorelbine (VIN) combined with paclitaxel (P) and radiation (XRT). Methods: Eligible patients (pts) had unresectable LABC, ECOG performance 0–2 and adequate organ function. Prior chemotherapy and metastatic disease were permitted. All pts received weekly bolus P 80 mg/m2 and concurrent XRT at 2.0 Gy daily for 5 days in a week-on/week-off (WO/WO) schedule for 12 weeks. A planned 59 -70 Gy were delivered to the breast, chest wall and supraclavicular regions. In dose level 2, VIN 15 mg/m2 /week was added. Results: Twenty-six pts were enrolled from July 1999-July 2005 with a median age of 51 years (range 24–69); 9 pts had stage IV disease, 17 pts had stage IIIB disease, and 13 pts had received prior chemotherapy. VIN was not tolerated due to grade (G) 4 neutropenia despite GCSF; however single-agent P and concurrent XRT was well-tolerated. Thus, 7 pts in the final cohort received P/XRT without GCSF. This regimen was well-tolerated; toxicities seen included: G3 in-field skin desquamation 4/7; G4 lymphopenia 7/7, G3 infection 1/7; G3 wound dehiscence 1/7. After therapy, 20/26 pts underwent mastectomy: 6 pts had a pathologic complete response (no invasive disease), 12 had a pathologic partial response (scattered microscopic disease), and 2 pts had no response. Overall pathologic response rate was 90% for pts undergoing mastectomy; only 3 of the 20 resectable pts are alive without relapse a mean of 19.5 months after mastectomy. Conclusions: Neoadjuvant P 80 mg/m2 with full dose XRT in a WO/WO schedule is tolerable and effective allowing 20/26 unresectable pts to undergo successful mastectomy. Pts do not require routine GCSF support. Although most pts eventually relapse distantly, this regimen does render some pts not responding to initial doxorubicin-based therapy resectable.

[Table: see text]

No significant financial relationships to disclose.

Post-duty psychomotor performance in young and senior anaesthetists

BACKGROUND AND OBJECTIVE

The level of performance in junior and senior anaesthetists was investigated after 24-h shift working and on-call duties.

METHODS

Pre- and post-duty psychomotor function, influence on response time, cognitive function and well-being in 23 individuals (13 junior and 12 senior anaesthetists) was assessed before and after 24-h in-house on-call duty. Subjective perception of tiredness and concentration abilities was estimated by applying a visual analogue scale.

RESULTS

The self-assessed tiredness prior to duty was high in both age groups and significantly increased in senior anaesthetists after night duty (P = 0.01). Post-duty impairment of concentration abilities was reported in both groups. Comparing results from pre- and post-duty psychometric testing showed a comparable decline in junior and senior anaesthetists as well. Assessment of burnout showed a significant lack of personal accomplishment in junior anaesthetists as compared to their older colleagues (P = 0.038). Senior anaesthetists judged their contribution to patient well-being significantly higher than did their younger colleagues (P = 0.035).

CONCLUSIONS

Although tiredness and subjective impairment of concentration abilities was high in senior anaesthetists after 24-h in-house on-call duty, performance assessed by psychometric testing does not support the hypothesis that senior colleague's performance cannot keep up with routine hospital shift work.

Risk for tuberculosis infection among internally displaced persons in the Republic of Georgia

OBJECTIVE

To determine the prevalence of tuberculosis (TB) infection and disease among internally displaced persons residing in Tbilisi, Republic of Georgia.

DESIGN

Residents of eight refugee hostels were screened for TB infection using a tuberculin skin test (TST) and a symptom questionnaire. Participation was voluntary. TST-positive individuals were referred for chest radiography. Subjects with cough, fever, or night sweats of > 2 weeks duration provided sputum for acid-fast bacilli (AFB) microscopy and culture.

RESULTS

Of approximately 4000 potential subjects (internally displaced persons), 988 (24.7%) participated in the screening program. Of these 988, 931 (94.2%) who had a TST placed returned at 48-72 hours to have the skin test examined; 447 (48.0%) were TST-positive (> or = 10 mm induration). In multivariate analysis, risk factors for a positive TST included male sex, ever having received BCG, history of close contact with a case of active tuberculosis, and living in one specific refugee hostel. Risk for a positive TST was greater among subjects > 20 years old, but there was no difference between age groups over the age of 20 years. Five patients with active TB were identified through the screening program, giving a case rate of 537 per 100,000 population.

CONCLUSION

Tuberculosis infection and disease were common in this group of internally displaced persons. Screening was a useful mechanism of case finding among this high prevalence population.

[Simultaneous occurrence of cervicofacial an pleuropulmonary actinomycosis]

Successful treatment of rapidly spread cervicofacial and pleuropulmonary actinomycosis case is reported. Significant law destruction and pathological fractures were observed as well.

[The use of human lyophilized bone matrix gelatin in oral surgery (preliminary report)]

Clinical application of human freeze-dried bone matrix gelatin (BMG) in the bone-cysts is reported. The BMG is produced at the West Hungarian Regional Tissue Bank in Gyór under principles of the American and European Association of Tissue Banks. BMG was applied to fill bone cysts in maxilla and mandible. The BMG has many advantages in comparison to other materials in the management of maxillofacial cysts. Of 31 cases 28 primary bone-heating have been detected clinically assessed by X-ray and histologically in three cases there was secondary restoration. In the favourable courses very fast and effective restorations have been found. The authors possess very favorable experience on the field of implantation of human bone matrix gelatin and recommend its clinical application at the maxillofacial surgery.