Epidermal growth factor receptor T790M mutation: A major culprit in the progression of epidermal growth factor receptor-driven non-small cell lung cancer and the role of repeat biopsy

Non-small cell lung cancer (NSCLC) accounts for the majority of primary lung cancer cases worldwide. The activating mutations of epidermal growth factor receptor (EGFR) have been demonstrated to associate with the development of NSCLC, with T790M mutation being the most common. Over the years, EGFR tyrosine kinase inhibitors (TKIs) were developed to target EGFR-related mutations. However, patients with activating EGFR mutations who are initially responsive to EGFR-TKIs eventually develop acquired resistance after a median progression-free survival of 10-16 months, followed by disease progression. Recently, the third-generation EGFR inhibitors have emerged as potential therapeutics to block the growth of EGFR T790M-positive tumors. This article reviews the emerging data regarding EGFR mutations and clinical evidence on third-generation agents against EGFR T790M mutation in the treatment of patients with advanced NSCLC. It also reviews the role of repeat biopsy in improving the success rates of treatment of EGFR T790M-derived drug-resistant NSCLC.

Practical consensus recommendatons for Paget's disease in breast cancer

Paget's disease of the breast is a rare type of cancer of the nipple-areola complex and that is often associated with an underlying in situ or invasive carcinoma. Diagnosis and treatment of Paget's disease is controversial. Expert oncologists discuss on the update on the approaches of Paget's disease diagnosis and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations on management of triple-negative metastatic breast cancer

Patients with breast cancer along with metastatic estrogen and progesterone receptor (ER/PR)- and human epidermal growth factor receptor 2 (HER2)-negative tumors are referred to as having metastatic triple-negative breast cancer (mTNBC) disease. Resistance to current standard therapies such as anthracyclines or taxanes limits the available options for previously treated patients with metastatic TNBC to a small number of non-cross-resistant regimens, and there is currently no preferred standard chemotherapy. Clinical experience suggests that many women with triple-negative metastatic breast cancer (MBC) relapse quickly. Expert oncologist discussed about new chemotherapeutic strategies and agents used in treatment of mTNBC and the expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendation on when to do BRCA testing

BRCA-mutation associated breast cancer and to future cancer risks and sensitivity to systemic therapies. Now that rapid genetic testing for BRCA1 and BRCA2 mutations is available, BRCA mutation status can be considered when making treatment and prevention decisions for BRCA testing, BRCA mutation carriers with breast cancer. Expert group used data from published literature, practical experience, and opinion of a large group of academic oncologists, to arrive at practical consensus recommendations for use by the community oncologists.

Practical consensus recommendations regarding the management of HER2 neu positive early breast cancer

Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations with regards to the use of these agents and the management of HER2 neu early breast cancer for the benefit of community oncologists.

Abstract P6-11-02: Voice of cancer patients: Analysis of patient concerns regarding scalp cooling devices for prevention of chemotherapy induced alopecia

Adjuvant chemotherapies for breast cancer cause hair loss in majority of patients. Although Chemo Induced Alopecia (CIA) is temporary, is distressing for many patients and about 7% patients treated with docetaxel experience permanent hair loss. Scalp cooling devices (SCDs) have been shown to reduce hair loss in patients receiving chemo.

Many patients share their experiences in online forums as freely shared messages and can be used to analyze concerns regarding CIA and SCDs. We use our automated system, VoCP, to analyze these messages and assess the utilization and efficacy of SCDs, concerns and associated barriers.

Method: We collected 15.13 million unique messages (987,189 patients) from 37 cancer forums that provide clinically relevant information; we built custom ontologies for chemo drugs and regimens, hair loss, SCDs, supportive therapy and efficacy. We then used VoCP (using techniques from Artificial Intelligence - deep learning, information retrieval and natural language processing) to extract relevant information.

Results: Out of 15.13 million, 17,966 messages from 4,258 patients discussed the use of SCDs during chemo. 16,527 of these were inquiring about SCDs, e.g., do SCDs work, side effects, Difficulty in use, risk of scalp and brain metastasis, cost and insurance coverage, ease of obtaining and manufacturers.

2,213 messages from 817 patients discussed SCDs with Docetaxel, 1,470 from 687 patients discussed with FEC/AC, and 517 from 249 patients discussed with AC/Taxol.

In 1,439 messages, 668 distinct patients who used SCDs mentioned that, they were able to keep 50-75% of their hair but experienced significant hair-thinning. Most users were satisfied with SCDs' use and would prefer them over loosing hair completely; comments regarding side effects, barriers and advice included:

· Headaches, shivering, frost-bite, heaviness, neck and shoulder discomfort, chills, brain freeze, scalp pain, migraine, drowsiness, dizziness and cold; May use Lorazepam, Ibuprofen and Acetaminophen.

· Use mittens/hand-gloves, scarves, blankets and heating pads to keep body warm and avoid shivering

· Use cold caps during and 3-5 hours after chemo; change them every 15-30 minutes

· Cold caps with varying temperatures - warmer in front and sides for ear and forehead protection – may help; trim long hair

· For cold caps, either the facility needs to provide a freezer or patients need to bring their own

· Penguin cold caps are most common (2,055 messages) but monthly rent is $500-$600

· Patients can buy Elastogel caps (918 messages) for about $100

· Alternatives include icepacks/wrap-arounds provided by companies such as ElastoGel

· For single cap cooling devices such as DigniCap (337 messages) and Paxman (434), facility has to provide the system

· Rapunzel Project (171 messages) can help with scalp cooling gear, freezers and counseling; 79 SCD users mentioned getting their help

Discussion: Despite significant discomfort, cost and inconvenience, many patients are satisfied with SCDs' use for CIA. More programs like Rapunzel project are needed to help patients.

By analyzing millions of messages, VoCP provides meaningful insights into patients' treatment and concerns and gives insight into unmet needs for further research and resources.

Citation Format: Aggarwal S, Sharma R, Sharma R, Aggarwal A. Voice of cancer patients: Analysis of patient concerns regarding scalp cooling devices for prevention of chemotherapy induced alopecia [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 P6-11-02.

Abstract P4-06-14: Voice of cancer patients: Association of family history with genetic mutations in breast and ovarian cancer

There are specific guidelines for testing germline mutations in patients with breast cancer. Besides BRCA 1 and 2, germline mutations of multiple other genes are being recognized as risk factors for breast and ovarian cancers and hence more patients are being tested using multigene panels.

Many patients share their experiences as freely shared messages in online forums. In this study, we use our automated system (VoCP) to analyze these messages to understand awareness of genetic testing in breast cancer patients and some factors that lead to their genetic testing.

Method: We collected 15.13 million unique messages (by 987,189 users) from 37 unrestricted cancer forums that provide clinically relevant information. We built custom ontologies for genetic tests; breast, ovarian and other cancers; risk reducing mastectomy and oophorectomy; and screening. We then used VoCP that uses techniques from Big Data Science and Artificial Intelligence (e.g., deep learning, topic modeling, information retrieval, and natural language processing) to extract relevant information from these messages.

Results: Out of 15.13 million, 30,074 messages from 7,838 distinct users were discussing genetic testing. Mutations that were discussed most include:

· BRCA1/BRCA2 (28,130 messages); 954 patients were positive

· PALB2 (218 messages); 114 were positive

· CHEK2 (315 messages); 149 were positive

· TP53 (180 messages); 55 were positive

· BRIP1 (76 messages); 36 were positive

· CDH1 (128 messages); 12 were positive

· NBN (80 messages); 28 were positive

· STK11 (48 messages); 2 were positive

· RAD50/ RAD51C (39 messages/48 messages)

Association with family history of cancer: 3,083 messages mentioned positive family history and some mentioned several cancers in their family; these messages discussed the following cancers:

· Breast cancer: 2,243 massages

· Ovarian cancer: 830 massages

· Colon cancer: 247 messages

· Pancreatic cancer: 121 massages

· Prostate cancer: 206 massages

· Lung cancer: 138 messages

Out of 954 BRCA 1 and 2 positive patients,

· 279 messages indicated their family members were tested for BRCA 1 and 2

· 156 messages indicated positive mutations were found in family members

· 23 messages indicated that male members of family were also being tested

Also, out of 954 BRCA 1 and 2 positive patients,

· 333 mentioned opting for bilateral mastectomy and 117 talked about getting Prophylactic Bilateral Salpingo Oophorectomy

· 309 messages talked about ovarian cancer once they found out that they have BRCA mutation

Discussion:There is increasing awareness of genetic testing and germline mutations in addition to BRCA 1 and 2 in breast cancer. Positive family history of cancer is mentioned in 10% of patients seeking genetic testing.

VoCP reliably provides meaningful insights from patients' point of view to their treatment and their concerns; it also gives insight into unmet needs where more resources and research should be focused.

We plan to use VoCP for further segmenting these 30,074 messages to understand other attributes and awareness among such patients.

Citation Format: Aggarwal S, Sharma R, Sharma R, Aggarwal A. Voice of cancer patients: Association of family history with genetic mutations in breast and ovarian cancer [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 P4-06-14.

Differentially regulated gene expression in quiescence versus senescence and identification of ARID5A as a quiescence associated marker

In multicellular organisms majority of the cells remain in a non-dividing states of either quiescence (reversible) or senescence (irreversible). In the present study, gene expression signatures unique to quiescence and senescence were identified using microarray in osteosarcoma cell line, U2OS. It was noted that certain genes and pathways like NOD pathway was shared by both the growth arrest conditions. A major highlight of the present study was increased expression of number of chemokines and cytokines in both quiescence and senescence. While senescence-associated secretory phenotype (SASP) is well known, the quiescence-associated secretory phenotype (QASP) is relatively unknown and appeared novel in this study. ARID5A, a subunit of SWI/SNF complex was identified as a quiescence associated gene. The endogenous expression of ARID5A increased during serum starved condition of quiescence. Overexpression of ARID5A resulted in more number of cells in G0/G1 phase of cell cycle. Further ARID5A overexpressing cells when subjected to serum starvation showed a pronounced secretory phenotype. Overall, the present work has identified gene expression signatures which can distinguish quiescence from senescence.

Serial perioperative cell-free DNA levels in donors and recipients undergoing living donor liver transplantation

BACKGROUND

Effect of anaesthesia and surgery on cell-free DNA (cfDNA) is not known. Given that surgical stress augments inflammation and injury, we hypothesized that levels of cfDNA will fluctuate during perioperative period. Therefore, in this study serial perioperative cfDNA concentration was measured in donors and recipients undergoing living donor liver transplantation (LDLT).

METHODS

Baseline, post-induction, intraoperative and post-operative plasma cfDNA levels were evaluated in 21 donors and recipients each, by Sytox green method. In addition, qPCR was performed in a subset of samples.

RESULTS

Baseline cfDNA levels were higher in recipients (37.62 ng/ml) than in donors (25.49 ng/ml). A decrease in cfDNA was observed following anaesthesia induction in both recipients (11.90 ng/ml) and donors (10.75 ng/ml). When the kinetics of the cfDNA was monitored further, an increase was noted intraoperatively in donors (46.18 ng/ml) and recipients (anhepatic phase: 56.25 ng/ml, reperfusion phase: 54.36 ng/ml). cfDNA levels remained high post-operatively. One recipient who developed post-operative sepsis had the highest cfDNA level (94.72 ng/ml).

CONCLUSION

Plasma cfDNA levels are high in recipients indicative of liver injury. Lower cfDNA levels following induction may be attributed to the subduing effect of anaesthetic agents on cell death. High cfDNA levels seen in intra- and post-operative phases reflect cellular trauma and inflammation. This similar pattern of fluctuation of cfDNA level in donors and recipients is suggestive of its possible utility as a surgical stress marker. In addition, comparable cfDNA levels in anhepatic and reperfusion phase reflect less ischemia reperfusion injury during LDLT.

Insulinoma Presenting with Neuropsychiatric Symptoms

An insulinoma is a rare pancreatic endocrine tumor which is typically a hypervascular, solitary small tumour. 90 % of tumors are benign and less than 2 cm in size. Some insulinomas are associated with MEN-1 syndrome. Some cases of insulinoma may present with neuropsychiatric symptoms and may be wrongly diagnosed as psychosis. We report a case of insulinoma in a 55 years old female who presented with episodes of abnormal behavior and altered sensorium. On detailed investigations she was diagnosed as a case of hyperinsulinemic hypoglycemia due to insulinoma (in her case MRI abdomen was normal) DOTANOC PET CT confirmed the insulinoma in body/tail of pancreas.

Faecal occult blood testing screening for colorectal cancer and 'missed' interval cancers: are we ignoring the elephant in the room? Results of a multicentre study

AIM

Biennial faecal occult blood testing (FOBT) is used to screen for colorectal cancer throughout the UK. Interval cancers are tumours that develop in patients between screening rounds who have had a negative FOBT. Through a multicentre study, we compared the demographics of patients with interval cancers, FOBT screen detected cancers and cancers that developed in patients who chose not to participate in the screening programme.

METHOD

Five hundred and sixteen colorectal cancers were detected in the screening age group (60-74 years) population in three UK National Health Service hospitals over 2 years. One hundred and twenty seven (25%) were interval cancers, 161 (31%) were screen detected and 228 (44%) were cancers that developed in patients who had declined FOBT. The interval cancer group had a higher incidence of right-sided cancers (38% vs 29% and 24%), a higher proportion of high tumour stages (Dukes C and D) (70% vs 53% and 33%) and a shorter time from diagnosis to death (10 months vs 13 months and 24 months) compared to patients who had declined the FOBT and the FOBT screen detected cancers. Of all the patients studied, those with right-sided interval cancers had the worst outcome.

CONCLUSION

A quarter of the colorectal cancers diagnosed in our study were interval cancers. Patients with right-sided interval cancers had the highest proportion of Dukes C and D tumours coupled with the shortest survival time after diagnosis compared with the other groups.

Practical recommendation for rash and diarrhea management in Indian patients treated with tyrosine kinase inhibitors for the treatment of non-small cell lung cancer

Tyrosine kinase inhibitors (TKIs) are a pharmaceutical class of small molecules, orally available with manageable safety profile, approved worldwide for the treatment of several neoplasms, including lung, breast, kidney and pancreatic cancer as well as gastro-intestinal stromal tumours and chronic myeloid leukaemia. In recent years, management of lung cancer has been moving towards molecular-guided treatment, and the best example of this new approach is the use of the tyrosine kinase inhibitors (TKIs) in patients with mutations in the epidermal growth factor receptor (EGFR). The identification of molecular predictors of response can allow the selection of patients who will be the most likely to respond to these tyrosine kinase inhibitors (TKIs). Gastrointestinal (GI) adverse events (AEs) are frequently observed in patients receiving EGFR tyrosine kinase inhibitor therapy and are most impactful on the patient's quality of life. Dermatologic side effects are also relatively common among patients treated with EGFR inhibitors. Evidence has emerged in recent years to suggest that the incidence and severity of rash, positively correlated with response to treatment.These skin disorders are generally mild or moderate in severity and can be managed by appropriate interventions or by reducing or interrupting the dose. Appropriate and timely management make it possible to continue a patient's quality of life and maintain compliance; however if these adverse events (AEs) are not managed appropriately, and become more severe, treatment cessation may be warranted compromising clinical outcome. Strategies to improve the assessment and management of TKI related skin AEs are therefore essential to ensure compliance with TKI therapy, thereby enabling patients to achieve optimal benefits. This article provides a consensus on practical recommendation for the prevention and management of diarrhoea and rash in Non-Small Cell Lung Cancer (NSCLC) patients receiving TKIs.

Abstract P5-13-04: Voice of cancer patients: Analysis of patient concerns regarding pregnancy and fertility preservation in patients with breast cancer

Breast cancer accounts for one third of all cancers seen in reproductive-age women. Adjuvant chemotherapy regimens used for treatment commonly affect fertility and cause premature ovarian failure. Fertility preservation in young cancer survivors is recognized as a key survivorship issue by the American Society of Clinical Oncology and the American Society of Reproductive Medicine. Many patients share their experiences in online forums, which contain millions of freely shared messages that can be used to analyze concerns regarding pregnancy and fertility preservation. However, this data is unstructured and difficult to analyze. We organize it using methods from Big Data Science (BDS) and analyze it by creating a Decision Support System (DSS) and an interface that can be used by patients and by providers to understand concerns of these patients.

Method:

We collected 5.8 million unique messages (by 170,000 users) from 20 unrestricted breast cancer forums that provide clinically relevant information. We next built custom ontologies for breast cancer, treatment, pregnancy and fertility and supportive therapies. We then created a DSS using methods from BDS, including topic modeling, information retrieval, and natural language processing to extract relevant information from these messages.

To use this system, a user provides disease-related parameters, key questions and the treatment. The DSS then gives messages discussing a similar cohort of patients that have similar parameters and are going through similar treatments.

Results:

Of 170,000 patients, only 5,109 patients reported their age and 1,604 patients reported their age below 45 years. 2,378 patients posted 6,377 messages discussing pregnancy and fertility related issues during Breast-Cancer treatment, and of these, 907 reported their age below 45.

Their specific concerns included:

· Does pregnancy increase the risk of recurrence (31 messages from 24 patients)

· Chances of successful pregnancy in patients who are 30 to 39 years old

· Risk of birth and genetic defects (23 messages from 21 patients)

Fertility options being discussed:

· Freezing embryos, eggs, or ovarian tissues. (169 messages from 138 patients)

· Artificial Insemination, hormone assisted pregnancy, or ovarian stimulation- in vitro fertilization (55 messages from 43 patients)

· Use of GNRH to preserve fertility during chemo with Lupron (291 messages) and Zolodex ( 391 messages)

Other findings include:

· 893 messages talked about stopping tamoxifen early, mostly within first 1.5 to 3 years so as to try the pregnancy option and 116 patients said that they stopped tamoxifen early.

· 83 patients talked about a successful pregnancy. Only 40 patients discussed getting fertility experts involved early.

Conclusion:

· This interactive system reliably provides meaningful insights from patient's point of view to their treatment, their concerns, and suggestions for supportive therapy. It also gives insight into unmet needs where more resources and research should be focused.

· Fertility preservation is a major concern in pre-menopausal patients. It should be addressed early on to prevent patients taking harmful decisions such as cutting short their hormonal therapy.

· Fertility counseling seems to be underutilized.

Citation Format: Aggarwal S, Sharma R, Sharma R, Gupta A, singh D, Aggarwal A. Voice of cancer patients: Analysis of patient concerns regarding pregnancy and fertility preservation in patients with 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 P5-13-04.

Impact of prior treatment on patients with relapsed multiple myeloma treated with carfilzomib and dexamethasone vs bortezomib and dexamethasone in the phase 3 ENDEAVOR study

The randomized phase 3 ENDEAVOR study (N=929) compared carfilzomib and dexamethasone (Kd) with bortezomib and dexamethasone (Vd) in relapsed multiple myeloma (RMM). We performed a subgroup analysis from ENDEAVOR in patients categorized by number of prior lines of therapy or by prior treatment. Median progression-free survival (PFS) for patients with one prior line was 22.2 months for Kd vs 10.1 months for Vd, and median PFS for patients with ⩾2 prior lines was 14.9 months for Kd vs 8.4 months for Vd. For patients with prior bortezomib exposure, the median PFS was 15.6 months for Kd vs 8.1 months for Vd, and for patients with prior lenalidomide exposure the median PFS was 12.9 months for Kd vs 7.3 months for Vd. Overall response rates (Kd vs Vd) were 81.9 vs 65.5% (one prior line), 72.0 vs 59.7% (⩾2 prior lines), 71.2 vs 60.3% (prior bortezomib) and 70.1 vs 59.3% (prior lenalidomide). The safety profile in the prior lines subgroups was qualitatively similar to that in the broader ENDEAVOR population. In RMM, outcomes are improved when receiving treatment with carfilzomib compared with bortezomib, regardless of the number of prior therapy lines or prior exposure to bortezomib or lenalidomide.

Dealing with sub-trochanteric fracture in a child with osteopetrosis : A case report

Osteopetrosis is a rare hereditary condition which may have autosomal recessive or autosomal dominant inheritance. Patients tend to present most commonly with fractures but involvement of cranial nerves and hematopoetic system is not uncommon. Patients with infantile and intermediate type tend to present more often with problems other than orthopaedic problems. While diagnosis can be made on the basis of radiographs, management needs to be customized for every patient. Non operative and operative management both have their advantages and disadvantages. We are here reporting a case of sub-trochanteric fracture in an eight-year-old child which was managed successfully with a dynamic hip screw (DHS). Surgery could be performed successfully by taking precautions during reduction, drilling and screw placement. At the latest follow up, which was after one and half years of surgery, the fracture had united well and the child faced no limitations of activities. Thus, open reduction and fixation with DHS can be considered as an effective management modality for pediatric sub-trochanteric fractures in osteopetrosis.

Conventional cytology, visual tests and evaluation of P16(INK4A) as a biomarker in cervical intraepithelial neoplasia

OBJECTIVES

(1) To detect cervical intraepithelial neoplasia (CIN) using Papanicolaou test (PAP test), visual tests (visual inspection after the application of acetic acid [VIA], visual inspection after the application of Lugol's iodine [VILI]), colposcopy, and biopsy. (2) To study the biomarker p16(INK4A) expression by immunostaining.

MATERIALS AND METHODS

Experimental study was conducted from November 2009 to April 2011. 1500 women were screened for cancer cervix using conventional PAP test, VIA, and VILI. Sensitivity, specificity, positive, and negative predictive values of these tests were calculated individually, sequentially, and in parallel. Women having positive results underwent colposcopy and biopsy if required. p16(INK4A) expression in biopsy samples was studied using immunohistochemistry.

RESULTS

All test positive cases (n = 235) underwent colposcopy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PAP with atypical squamous cells of undetermined significance (ASCUS) as cut-off was 40%, 99.25%, 35.25%, and 99.39%; VIA was 60%, 93.06%, 8.03%, and 99.56% and VILI was 80%, 86.06%, 5.4%, and 99.76%, respectively. When PAP, VIA, and VILI were used in parallel sensitivity, specificity, PPV, and NPV improved to 100%, 85.18%, 6.38%, and 100%, respectively. Colposcopic abnormalities were detected in 83 and biopsy proven CIN in 15. p(16INK4A) expression was seen in eight of 15 CIN cases.

CONCLUSIONS

(1) PAP test and visual techniques are complementary. (2) p(16INK4A) expression was seen in majority of CIN 2 lesions suggesting a higher grade lesion.