Cohort study of long-term survival and quality of life following pelvic exenteration

BACKGROUND

Pelvic exenteration (PE) is the preferred treatment available for selected patients diagnosed with locally advanced or recurrent cancer confined to the pelvis. Currently, the majority of the literature reports only on short-term survival and quality-of-life (QoL) outcomes. The aim of this prospective cohort study was to describe long-term survival and QoL outcomes following PE.

METHODS

This was a cohort study of consecutive patients undergoing PE from 1994 to 2016 at a major teaching hospital in Sydney, Australia. From 2008, consenting patients were also included in a prospective QoL study. Main outcomes were long-term survival and QoL assessed with SF-36® and FACT-C questionnaires. Survival was estimated using the Kaplan-Meier method.

RESULTS

Some 515 patients underwent PE for locally advanced or recurrent cancer. The cumulative 5- and 10-year overall survival rates were 48·6 and 37·8 per cent respectively. The survival estimates were significantly higher for patients with advanced primary rectal cancer (P = 0·045) and those in whom a clear resection margin was achieved (P < 0·001). Some 287 patients were enrolled into the QoL study. Response rates at baseline, 6 months and 5 years were 92·0, 70·0 and 33 per cent respectively. Patients had recovered to their preoperative QoL status by 6 months and, among survivors, QoL remained essentially unchanged during the 5-year follow-up.

CONCLUSION

Patients who underwent PE owing to advanced primary rectal cancer or achieved a clear resection margin had a greater chance of survival. Overall, QoL returned to baseline within 6 months after surgery.

Quantitative and rapid interference of bovine viral diarrhea virus BVDV/END- and BVDV/END+ strains

Homologous interference in vitro is defined as the ability of primary viral infection to prevent secondary homologous superinfection. Non-cytopathic bovine viral diarrhea virus (ncp BVDV) has been classified according to the exaltation of Newcastle disease phenomenon (END) as END positive (E+) and END negative (E-) strains. Simultaneous inoculation of MDBK-SY cell monolayers with BVDV/E- virus and a three log higher amount of BVDV RK13/E+ virus, leads to acquisition of the BVDV/E- feature of blocking Newcastle disease virus (NDV) infection in cells. BVDV/E- strains, particularly at a high titre and MOI ≥1.25, can exert and impose their effects in BVDV/E+ infected cells; however, if BVDV/E- MOI is reduced to MOI below 0.625, the BVDV/E+ effect can be restored leading to cytopathic effects (CPE) induction by NDV reciprocal to the titre of the BVDV RK13/E+ strain. Moreover, blocking and prevention of induced CPE by NDV or vesicular stomatitis virus (VSV) occurs even when BVDV/E- superinfects primary BVDV/E+ infected cells, indicating a defective homologous interference between BVDV/E+ and BVDV/E- strains. Taken together, BVDV/E- strains have a strong competitive potency and mediate a fast acting (i.e. within 60 min) influence against BVDV/E+ activity. This may be relevant in vivo where BVDV/E- and BVDV/E+ combinations are frequently isolated from infected individuals.

Abstract P3-05-02: Immune profiling of paired primary and recurrent triple negative breast cancer

Background: Triple negative breast cancer (TNBC) is a heterogeneous disease with several molecular subtypes: basal-like1 (BL-1), basal-like 2 (BL-2), mesenchymal (M), and luminal androgen receptor (LAR). Molecular evolution of TNBC through chemotherapy selection pressure is well recognized but poorly understood. In addition, approximately 20% of TNBCs respond to PD-1 or PD-L1 inhibitors. It has been observed that heavily pre-treated patients may not respond well to immunotherapy. This study was carried out to perform immune profiling of paired primary and recurrent TNBC. Here we report the result of the first 10 paired tissue pilot analysis.

Methods: Twenty specimens were identified through an IRB-approved protocol via the City of Hope Biospecimen Repository (2002-2015). Two brain and one bone metastasis specimens were not included due to technical difficulty. Formalin-fixed paraffin embedded (FFPE) sample blocks were cut into 5-mm thick slides and labeled with the following antibodies: CD4, CD8, CD3, FOXP3, CD20, CD33, Pan-CK, and PD-1 using the multiplex IHC opal method. Image acquisition and cell counting were carried out using PerkinElmer Vectra automated quantitative pathology imaging system and inForm software analysis (PerkinElmer, Waltham, MA). mRNA expression profiling was performed using Affymetrix Human Genechip 2.0. Raw data were normalized and processed using Expression Console. Using Vanderbilt TNBC sub-classification tool, we have sub-classified the 20 primary and recurrent TNBC specimens. Tumor mutation burden (TMB) was generated through FoundationOne® platform.

Result: A total of 17 samples were analyzed (M, 5; LAR, 3; BL-1, 4; BL-2, 5). M-subtype had a significantly lower tumor-infiltrating CD3+ T cells (p=0.005), CD8+ T cells (p=0.024), CD4+ T cells (p=0.065) and CD4+FOXP3+ Treg cells (p=0.054), irrespective of the site of metastasis. CD20+ B cells were particularly enriched in BL-1 subtype (p=0.0013, 23.5% of 17 samples). Of 17 samples, 8 had TMB. Seven had low TMB (&lt;10 mut/Mb) and one had intermediate TMB (11 mut/Mb, LAR subtype). The tumor with intermediate TMB had the highest quantity of tumor-infiltrating CD3+ T cells, CD8+ T cells, CD8+PD1+ T cells, and CD4+FOXP3+PD1+ Treg cells compared to the 7 tumors with low TMB. Compared with recurrent tumors, primary tumors had a significantly higher percentage of tumor-infiltrating T cells (TIL). To validate multiplexed IHC results, these samples were evaluated by a licensed pathologist at City of Hope using the International TILs Working Group 2014 guidelines, and there was a good correlation between percent of TILs and CD3+ T cells by IHC approach.

Conclusion: To our knowledge, this is the first study linking tumor immune cell profiles with the TNBC 4 subtypes. Distinctive immune cell patterns were observed among 4 TNBC subtypes. M subtype had significantly lower TILs, which may indicate poor response to checkpoint inhibitors. Further analysis of a total of 50 paired TNBCs is currently underway.

Contact information: Yuan Yuan MD PhD, Email: yuyuan@coh.org

Citation Format: He T-F, Yost S, Schmolze D, Wang R, Rosario A, Tu T, Chu P, Lee P, Yuan Y. Immune profiling of paired primary and recurrent triple negative breast 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 P3-05-02.

Abstract OT1-05-02: A phase II clinical trial of the combination of pembrolizumab and selective androgen receptor modulator GTx-024 in patients with advanced androgen receptor positive triple negative breast cancer

Background: Androgen receptor (AR) targeted therapy and immunotherapy represent one of the most promising strategies for metastatic triple negative breast cancer (mTNBC), which accounts for 15-20% of all breast cancers. As a nonsteroidal selective androgen receptor modulator (SARM), GTx-024 demonstrated preclinical activity in AR+ TNBC PDX model. Pembrolizumab is a highly selective humanized monoclonal antibody of the programmed cell death 1 receptor (PD-1). The complementary modes of action and low potential for overlapping toxicity make the combination promising in patients with AR+ mTNBC.

Trial Design: This is an open-label Phase 2 study for AR+ mTNBC. Eligible participants receive pembrolizumab 200mg IV every 3 weeks in combination with GTx-024 18mg po daily.

Eligibility Criteria: Eligible patients must have AR+ (&gt;10%, 1+ by IHC) TNBC; failed up to 2 lines of therapy in metastatic setting; and have measurable disease per RECIST1.1. Patients are excluded if they have had prior checkpoint inhibitors or AR targeted agents. Patients with current or prior use of testosterone, testosterone-like agents, androgenic compounds, or anti-androgens (including systemic steroids and immunosuppressive medications)are excluded, as well as current or prior history of noninfectious pneumonitis requiring systemic steroid therapy.

Specific Aims: The primary objective is to evaluate the safety/tolerability of GTx-024 and pembrolizumab and determine the response rate (CR or PR via RECIST 1.1) in patients with advanced AR+ TNBC. We will use clinical benefit rate (CBR), duration of response (DOR), PFS, and OS to test the efficacy of this novel drug combination.

Statistical Design: A Simon's MiniMax two-stage Phase 2 design will be utilized. Based on the previously reported response rate associated with single agent pembrolizumab (19%), we consider a response rate of 19% for the combination as discouraging, and a 39% response rate as encouraging. As a result, we will initially accrue 15 patients (including 6 patients from safety lead-in treated at the tolerable dose). If 2 or fewer patients respond, we will stop accrual for futility. Otherwise, the study will accrue an additional 14 patients for a total of 29 patients. With 29 patients, if only 8 or fewer respond (≤27.6%), the study will be considered discouraging unless secondary evidence of clinical benefit is substantial. With more than 8 patients responding out of the 29 patients, the combination would be considered promising. This design has 85% power to declare a true response rate of 39% as promising (power), and a 10% probability of declaring a true 19% response rate as encouraging (type I error). The probability of early termination if the true response rate is 19% is 44%.

Target Accrual: 29

Study Contact: Yuan Yuan MD PhD, City of Hope Comprehensive Cancer Center; Duarte, CA 91030; Email: yuyuan@coh.org

Citation Format: Yuan Y, Frankel P, Synold T, Lee P, Yost S, Martinez N, Tang A, Mendez B, Schmolze D, Apple S, Hurria A, Waisman J, Somlo G, Tank N, Sedrak M, Mortimer J. A phase II clinical trial of the combination of pembrolizumab and selective androgen receptor modulator GTx-024 in patients with advanced androgen receptor positive triple negative breast 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 OT1-05-02.

A prospective gating method to acquire a diverse set of free-breathing CT images for model-based 4DCT

Breathing motion modeling requires observation of tissues at sufficiently distinct respiratory states for proper 4D characterization. This work proposes a method to improve sampling of the breathing cycle with limited imaging dose. We designed and tested a prospective free-breathing acquisition protocol with a simulation using datasets from five patients imaged with a model-based 4DCT technique. Each dataset contained 25 free-breathing fast helical CT scans with simultaneous breathing surrogate measurements. Tissue displacements were measured using deformable image registration. A correspondence model related tissue displacement to the surrogate. Model residual was computed by comparing predicted displacements to image registration results. To determine a stopping criteria for the prospective protocol, i.e. when the breathing cycle had been sufficiently sampled, subsets of N scans where 5  ⩽  N  ⩽  9 were used to fit reduced models for each patient. A previously published metric was employed to describe the phase coverage, or 'spread', of the respiratory trajectories of each subset. Minimum phase coverage necessary to achieve mean model residual within 0.5 mm of the full 25-scan model was determined and used as the stopping criteria. Using the patient breathing traces, a prospective acquisition protocol was simulated. In all patients, phase coverage greater than the threshold necessary for model accuracy within 0.5 mm of the 25 scan model was achieved in six or fewer scans. The prospectively selected respiratory trajectories ranked in the (97.5  ±  4.2)th percentile among subsets of the originally sampled scans on average. Simulation results suggest that the proposed prospective method provides an effective means to sample the breathing cycle with limited free-breathing scans. One application of the method is to reduce the imaging dose of a previously published model-based 4DCT protocol to 25% of its original value while achieving mean model residual within 0.5 mm.

Abstract P1-08-04: Not presented

This abstract was not presented at the symposium.

Establishment and characterization of a new cell line from koi brain (Cyprinus carpio L.)

A novel permanently growing brain cell line from koi (Cyprinus carpio L.) (KB cell line) was established, and its suitability for detection of koi herpesvirus (KHV) was demonstrated in this study. The KB cell line was optimally maintained at 27°C in Leibovitz's L-15 medium supplemented with 10% foetal bovine serum (FBS). It was subcultured more than 100 times, and chromosome analysis revealed that 51.54% of KB cells at passage 80 maintained the abnormal diploid chromosome number 2n = 96 while the modal chromosome number was 2n = 100. The cell line was cryopreserved in liquid nitrogen at -196°C and was recovered from storage after 1 year with good cell viability and vitality. The results of virus isolation demonstrated that KB cells were susceptible to KHV, which was shown by the presence of an obvious cytopathic effect and abundant virus particles. The viral titres of KHV in KB reached 10^5.73 TCID₅₀ /0.1 ml within 7 days. Immunofluorescence and Western blot assays confirmed that KB replicated KHV. The newly established KB cell line will serve as a useful tool to elucidate KHV disease (KHVD) pathogenesis.