Effect of concomitant statin treatment in postmenopausal patients with hormone receptor-positive early-stage breast cancer receiving adjuvant denosumab or placebo: a post hoc analysis of ABCSG-18

Background

Statins are cholesterol-lowering drugs prescribed for the prevention and treatment of cardiovascular disease. Moreover, statins may possess anticancer properties and interact with receptor activator of nuclear factor κB ligand expression. We aimed at evaluating a hypothetical synergistic effect of statins with denosumab in early-stage breast cancer (BC) patients from the Austrian Breast and Colorectal Cancer Study Group (ABCSG) trial 18.

Patients and methods

ABCSG-18 (NCT00556374) is a prospective, randomized, double-blind, phase III study; postmenopausal patients with hormone receptor-positive BC receiving a nonsteroidal aromatase inhibitor were randomly assigned to denosumab or placebo. In this post hoc analysis, we investigated the effects of concomitant statin therapy on recurrence risk (RR) of BC, fracture risk and bone mineral density (BMD).

Results

In the study population (n = 3420), statin therapy (n = 824) was associated with worse disease-free survival (DFS) [hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.04-1.75; P = 0.023]. While no significant effect of lipophilic statins (n = 710) on RR was observed (HR 1.30, 95% CI 0.99-1.72; P = 0.062), patients on hydrophilic statins (n = 87) had worse DFS compared with patients not receiving any statins (HR 2.00, 95% CI 1.09-3.66; P = 0.026). This finding was mainly driven by the effect of hydrophilic statins on DFS in the denosumab arm (HR 2.63, 95% CI 1.21-5.68; P = 0.014). However, this effect subsided after correction for confounders in the sensitivity analysis. No association between statin use and fracture risk or osteoporosis was observed.

Conclusion

According to this analysis, hydrophilic statins showed a detrimental effect on DFS in the main model, which was attenuated after correction for confounders. Our data need to be interpreted with caution due to their retrospective nature and the low number of patients receiving hydrophilic statins.

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Statin co-medication was initially associated with a worse DFS in hormone receptor-positive early-stage BC patients.

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This effect was mainly driven by patients on hydrophilic statins.

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However, this effect subsided after correction for confounders in the sensitivity analysis.

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No association between statin use and fracture risk or osteoporosis was observed.

Pathologic complete response (pCR) to neoadjuvant treatment with or without atezolizumab in triple negative, early high-risk and locally advanced breast cancer. NeoTRIP Michelangelo randomized study

BACKGROUND

High-risk triple negative breast cancers (TNBC) are characterized by poor prognosis, rapid progression to metastatic stage and onset of resistance to chemotherapy, thus representing an area in need of new therapeutic approaches. PD-L1 expression is an adaptive mechanism of tumour resistance to tumour infiltrating lymphocytes, which in turn are needed for response to chemotherapy. Overall, available data support the concept that blockade of PD-L1/PD-1 check-point may improve efficacy of classical chemotherapy.

PATIENTS AND METHODS

Two-hundred-eighty patients with TNBC were enrolled in this multicentre study (NCT002620280) and randomized to neoadjuvant carboplatin AUC 2 and nab-paclitaxel 125 mg/m² iv on days 1 and 8, without (N = 142) or with (N = 138) atezolizumab 1200 mg iv on day 1. Both regimens were given q3 weeks for 8 cycles before surgery and 4 cycles of an adjuvant anthracycline regimen. The primary aim of the study is to compare event-free survival, an important secondary aim was the rate of pathological complete remission (pCR defined as absence of invasive cells in breast and lymph nodes). The primary population for all efficacy endpoints is the intention-to-treat population.

RESULTS

The intention-to-treat analysis revealed that pCR rate after treatment with atezolizumab (48.6%) did not reach statistical significance compared to no atezolizumab [44.4%: odds ratio (OR) 1.18; 95% CI 0.74-1.89; P = 0.48]. Treatment-related adverse events were similar with either regimen except for a significantly higher overall incidence of serious adverse events and liver transaminases abnormalities with atezolizumab.

CONCLUSIONS

The addition of atezolizumab to nab-paclitaxel and carboplatin did not significantly increase the rate of pCR in women with TNBC. In multivariate analysis the presence of PD-L1 expression was the most significant factor influencing rate of pCR (OR 2.08). Continuing follow up for the event-free survival is ongoing, and molecular studies are under way.

A clinical validation study of MammaPrint in hormone receptor-positive breast cancer from the Austrian Breast and Colorectal Cancer Study Group 8 (ABCSG-8) biomarker cohort

Background

MammaPrint is a prognostic assay based on gene expression in tumors from patients with early breast cancer. MammaPrint has been extensively validated and Food and Drug Administration cleared in fresh and formalin-fixed and paraffin-embedded (FFPE) tissue. We aimed to assess its prognostic performance in the biomarker cohort of the Austrian Breast and Colorectal Cancer Study Group 8 (ABCSG-8) patient population, and to obtain a higher level of evidence with regard to its clinical validity after RNA extraction from FFPE biobank tissue.

Patients and methods

A prespecified retrospective analysis to test the prognostic performance of the MammaPrint test to predict distant recurrence-free survival at 5 and 10 years as primary end point was carried out. MammaPrint risk, clinicopathological factors (after central pathological review), and clinical risk (using a modified version of Adjuvant! Online) were evaluated by Cox regression analyses.

Results

From 1347 available samples, 607 (45%) failed quality control after RNA extraction. In total, 658 (49%) patients were included in survival analyses: MammaPrint low risk versus high risk is a significant prognostic factor for distant recurrence-free survival at 5 years (94.0% versus 91.6%) with a significant risk reduction of 6.5% at 10 years (log-rank P value = 0.017, low risk 91.3% versus high risk 84.8%). The multivariable models suggest that hazard ratio (HR) is primarily driven by tumor stage (5-year HR 3.89; confidence interval 1.97-7.71) and nodal status (5-year HR 1.73; confidence interval 0.91-3.21). After adjustment for clinical risk groups, MammaPrint HRs remain stable with values just below 2.0 after the first 3 years.

Conclusions

The MammaPrint test showed significant prognostic performance at 5 and 10 years of follow-up. In the particular cohort of ABCSG-8, the statistical independence from clinically assessed covariates remains unclear, and no conclusions concerning the clinical validity of the test can be drawn.

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MammaPrint is a prognostic assay based on gene expression in tumors from patients with early breast cancer.

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MammaPrint has been extensively and successfully validated- but mostly in fresh tissue.

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We aimed to assess its prognostic performance in FFPE tissue from the ABCSG 8 biomarker cohort.

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The MammaPrint test showed significant prognostic performance at 5 and 10 years of follow-up.

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The statistical independence from clinically assessed covariates is unclear- the clinical validity in ABCSG 8 uncertain.

Primary surgery versus no surgery in synchronous metastatic breast cancer: patient-reported quality-of-life outcomes of the prospective randomized multicenter ABCSG-28 Posytive Trial

BACKGROUND

The ABCSG-28 trial compared primary surgery followed by systemic therapy versus primary systemic therapy without surgery in patients with de novo stage IV BC. The present report describes QoL results of this trial.

METHODS

Ninety patients with primary operable MBC were randomised to surgery of the primary tumor followed by systemic therapy or to primary systemic therapy without surgery. QoL analyses covering the results at baseline, 6,12,18 and 24 months follow up of 79 (88%) patients, was assessed with the EORTC QLQ-C30 and QLQ-BR23 questionnaires.

RESULTS

There were no statistically significant differences in any of the scales of the QLQ-C30 and QLQ-BR23 questionnaires between the two groups over the time. Baseline global health status and physical functioning were predictors for OS (patients with a higher score lived longer (p=0.0250, p=0.0225; p=0.0355, p=0.0355)). Global health status, social functioning scale, breast symptoms and future perspective were predictors for longer TTPd (p=0.0244; p=0.0140, p=0.020; p=0.0438, p=0.0123). Patients in both arms reported significant improvement on the emotional functioning scale. Cognitive functioning decreased over time in both groups. Younger women had clinically relevant better physical and sexual functioning scores (p=0.039 and 0.024).

CONCLUSION

Primary surgery does not improve nor alter QoL of patients with de novo stage IV BC. Global health status and physical functioning were predictors for OS and could be use as additional marker for prediction of OS and TTTd in patients with de novo stage IV BC.

TRIAL REGISTRATION

The trial is registered on clinicaltrial.gov (NCT01015625, date of registration:18/11/2009).

Abstract OT3-07-01: Ixazomib in combination with carboplatin in pretreated women with advanced triple negative breast cancer, an ongoing phase I/II trial (AGMT MBC-10 trial)

Background:Triple-negative breast cancer (TNBC) comprises a heterogeneous group of diseases which are generally associated with poor prognosis. Recently, the PARP inhibitor olaparib was approved as first targeted treatment beyond antiVEGF therapy for the BRCA1/2 mutated subgroup of TNBC. However, cytotoxic agents still remain the mainstay of treatment for this breast cancer subtype. Ixazomib is a selective and reversible inhibitor of the proteasome, which has been mainly investigated as treatment of multiple myeloma. In a preclinical cell line model for TNBC the first-generation proteasome inhibitor bortezomib showed synergistic efficacy with cisplatin. Clinical data are available for carboplatin plus bortezomib in metastatic ovarian and lung cancers showing remarkable antitumor activity (47% and 38% response rate, respectively) and good tolerability. In solid tumors cytotoxic effect of proteasome inhibitors is thought to be mediated through different mechanisms: (1) Inhibition of the Fanconi Anemia and BRCA1 DNA repair mechanism (2) Inhibition of p53 degradation (3) Inhibition of NF-kappa B signaling cascade. Based on this evidence, the phase I/II MBC-10 trial will evaluate the toxicity profile and efficacy of the oral second-generation proteasome inhibitor ixazomib in combination with carboplatin in patients with advanced TNBC. Trial Design: Patients with metastatic TNBC pretreated with at least one prior line of chemotherapy for advanced disease with a confirmed disease progression and measurable disease are eligible for this study.Patients will receive ixazomib in combination with carboplatin on days 1, 8, and 15 in a 28-day cycle. The phase I part of this study uses an alternate dose escalation accelerated titration design. After establishing the maximum tolerated dose (MTD), accrual continues to evaluate the efficacy and safety of the combination (phase II, including 41 evaluable patients). All patients will continue on study drugs until disease progression, unacceptable toxicity or discontinuation for any other reason. Primary endpoint of the phase II is overall response rate, secondary endpoints include safety profile, progression-free survival and quality of life. The MBC-10 trial is accompanied by a broad biomarker program investigating predictive biomarkers for treatment response and potential resistance mechanisms to the investigational drug combination. This trial is open for patient enrollment since November 2016 in six Austrian cancer centers. Accrual is planned to be completed within two years. ClinicalTrials.gov Identifier: NCT02993094

Citation Format: Rinnerthaler G, Gampenrieder SP, Petzer A, Burgstaller S, Voskova D, Rossmann D, Balic M, Egle D, Rumpold H, Singer CF, Petru E, Melchardt T, Ulmer H, Mlineritsch B, Greil R. Ixazomib in combination with carboplatin in pretreated women with advanced triple negative breast cancer, an ongoing phase I/II trial (AGMT MBC-10 trial) [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 OT3-07-01.

Abstract P6-21-02: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Minichsdorfer C, Bergen E, Steger GG, Pfeiler G, Frantal S, Greil R, Fohler H, Egle D, Balic M, Fitzal F, Wette V, Exner R, Bartsch RA, Gnant M. Withdrawn [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 P6-21-02.

Abstract OT2-07-11: Ixazomib in combination with carboplatin in pretreated women with advanced triple negative breast cancer, a phase I/II trial (AGMT MBC-10 trial)

Background: Triple-negative breast cancer (TNBC) comprises a heterogeneous group of diseases which are generally associated with a poor prognosis. Up to now, no targeted treatment beyond anti-VEGF therapy is approved for TNBC so far and cytotoxic agents are the mainstay for the treatment of advanced tumor stages. Ixazomib is a selective, and reversible inhibitor of the proteasome, which has been mainly investigated in the treatment of multiple myeloma. In a preclinical study triple-negative breast cancer cells were treated with bortezomib, a first generation proteaseome inhibitor, alone and in combination with cisplatin, which had a synergistic effect. Clinical data are available for carboplatin plus bortezomib in metastatic ovarian and lung cancers showing remarkable antitumor activity and good tolerability. Based on this rational, the MBC-10 trial will evaluate the toxicity profile and efficacy of ixazomib in combination with carboplatin in patients with advanced TNBC.

Trial Design: Patients with metastatic TNBC pretreated with at least one prior line of chemotherapy for advanced disease with a confirmed disease progression and measurable disease are eligible for this study. Patients will receive ixazomib in combination with carboplatin on days 1, 8, and 15 in a 28-day cycle. The phase I part of this study uses an alternate dose escalation accelerated titration design. After establishing the maximum tolerated dose (MTD), accrual continues to evaluate the efficacy and safety of the combination (phase II, including 41 evaluable patients). All patients will continue on study drugs until disease progression, unacceptable toxicity or discontinuation for any other reason. Primary endpoint of the phase II is overall response rate, secondary endpoints include safety profile, progression-free survival and quality of life. This trial is open for patient enrollment since November 2016 in six Austrian cancer centers. Accrual is planned to be completed within two years. ClinicalTrials.gov Identifier: NCT02993094

Citation Format: Rinnerthaler G, Gampenrieder SP, Petzer A, Pusch R, Fridrik M, Rossmann D, Balic M, Egle D, Rumpold H, Singer C, Bartsch R, Melchardt T, Ulmer H, Mlineritsch B, Greil R. Ixazomib in combination with carboplatin in pretreated women with advanced triple negative breast cancer, a phase I/II trial (AGMT MBC-10 trial) [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 OT2-07-11.

Abstract P6-10-01: Efficacy and safety of the therapeutic cancer vaccine tecemotide (L-BLP25) in early breast cancer: Results from a prospective, randomized, neoadjuvant phase-II study (ABCSG-34)

Background: Immune-based therapeutic strategies represent a promising approach in early and advanced breast cancer treatment. MUC1 glycoprotein is overexpressed and aberrantly glycosylated in over 90% of malignant breast cancer. It is involved in oncogenesis and confers resistance to anti-cancer therapies, thus representing a particularly promising target. Tecemotide is a MUC1-based therapeutic cancer vaccine. The aim of this trial was to investigate the efficacy and safety of preoperative tecemotide in primary breast cancer patients receiving neoadjuvant Standard-of-Care (SoC) treatment.

Patients and Methods: 400 patients with HER2-negative early breast cancer were recruited into this prospective, multicentre randomized 2-arm academic phase-II trial. Patients received preoperative SoC treatment with or without tecemotide therapy. Postmenopausal women with E+++, or E++ and Ki67 <14%, and G1,2,X tumors received 6 months of letrozole as SoC. Postmenopausal patients with triple-negative, E- or E+, or E++ and Ki67 ≥14%, and with G3 tumors, and all premenopausal patients received 4 cycles of epirubicin/cyclophosphamide plus 4 cycles of docetaxel as SoC. Patients were additionally randomized to receive reverse or conventional sequence of epirubicin/cyclophosphamide and docetaxel. Primary endpoint was histopathological response measured by Residual Cancer Burden (RCB0/I vs RCBII/III) at the time of surgery. Secondary endpoints included pCR, efficacy of reverse versus conventional sequence chemotherapy, and safety.

Results: We did not observe a significant difference in RCB0/I rates between patients with (36.4%) and without (31.9%) tecemotide in the overall study population (p = 0.40), and in endocrine and chemotherapy treated subgroups (25.0% vs 13.3%, p = 0.17; 39.6% vs 37.8%, p = 0.75). Similarly, addition of tecemotide did not affect overall pCR rates (22.5% vs 17.4%, p = 0.23). RCB0/I rates were comparable regardless of docetaxel being given before or after epirubicin/cyclophosphamide (37.2% vs 40.1%, p = 0.61). Tecemotide addition was not associated with a worse toxicity profile (178 AEs, 57 SAEs vs 180 AEs, 48 SAEs based on patient incidence).

Conclusion: Immune-based targeting of MUC1 by tecemotide is safe but does not improve RCB and pCR rates in early SoC-treated breast cancer.

Citation Format: Singer CF, Pfeiler G, Hubalek M, Bartsch R, Stoeger H, Pichler A, Petru E, Greil R, Rudas M, Tea M-KM, Wette V, Petzer AL, Sevelda P, Egle D, Dubsky PC, Balic M, Tinchon C, Bago-Horvath Z, Frantal S, Michael G. Efficacy and safety of the therapeutic cancer vaccine tecemotide (L-BLP25) in early breast cancer: Results from a prospective, randomized, neoadjuvant phase-II study (ABCSG-34) [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 P6-10-01.

Abstract P1-09-10: Pathological complete response to neoadjuvant trastuzumab is dependent on HER2/CEP17 ratio in HER2-amplified early breast cancer

Purpose To evaluate whether pathological complete response to neoadjuvant trastuzumab is dependent on the level of HER2 amplification.

Patients and Methods 114 women with HER2-overexpressing early breast cancer who had received neo-adjuvant trastuzumab in the prospective ABCSG-24 and ABCSG-32 trials, and for whom the HER2/CEP17 ratio was available, were included in this analysis. The ratio was correlated with tumor response as measured by the three most commonly used definitions of pathological complete response: ypT0 ypN0, ypT0/is ypN0, and ypT0/is.

Results In trastuzumab-treated patients, ypT0 pN0 was achieved in 69.0% of patients with a HER2/CEP17 ratio of >6, but only in 30.4% of tumors with a ratio of ≤6 (p=0.001, Chi Square test). When pCR was defined by ypT0/is pN0 or by ypTis, 75.9% and 82.8% of tumors with a high ratio had a complete remission, while only 39.1%, and 38.3% with a low ratio achieved a pCR (p=0.002 and p<0.001, respectively). Logistic regression revealed that tumors with a higher HER2/CEP17 ratio had a significantly higher probability to achieve ypT0 ypN0 (OR: 5.08, 95% CI 1.86-13.90; p=0.002) than tumors with a low ratio, while none of the other clinicopathological parameters was predictive of pCR. The association between high HER2 amplification and pCR was almost exclusively confined to HR positive tumors (62.5% vs. 24.0%, 75.0% vs. 28.0%, and 87.5% vs. 28.0%, for ypT0 ypN0, ypT0/is ypN0, and ypT0/is; p=0.014, p=0.005, and p<0.001), and was largely absent in HR negative tumors.

Conclusion A HER2/CEP17 ratio of >6 in the pre-therapeutic tumor biopsy is associated with a significantly higher pCR rate particularly in HER2 / HR co-positive tumors, and can be used to predict outcome before neoadjuvant trastuzumab is initiated.

Citation Format: Singer CF, Tan YY, Fitzal F, Steger GG, Egle D, Reiner A, Rudas M, Gruber C, Bartsch R, Fridrik M, Seifert M, Exner R, Balic M, Bago-Horvath Z, Filipits M, Gnant M, For the Austrian Breast and Colorectal Cancer Study Group. Pathological complete response to neoadjuvant trastuzumab is dependent on HER2/CEP17 ratio in HER2-amplified early 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 P1-09-10.

Abstract P2-09-22: Long-term psychosocial consequences and counsellees' satisfaction after genetic counselling for hereditary breast- and ovarian cancer - A patient reported outcome study

Background: Genetic counselling and testing (GCT) for hereditary breast and ovarian cancer (BOC) has become a standard option in BOC care in Europe allowing for prognostic information on the individual risk for disease onset/ relapse as well as on treatment options comprising prophylactic surgery or surveillance programs. However, data on the psychosocial long-term consequences is limited, especially in high-risk counsellees opting against genetic testing. We aimed at investigating the long-term psychosocial consequences of GCT for hereditary BOC in all counsellees irrespective of their decision after counselling.

Patients and Methods: Counsellees for BOC with and without a previous disease who had undergone genetic counselling at Innsbruck Medical University between 2011 and 2014 were asked to participate in a cross-sectional Patient Reported Outcome (PRO) assessment (incl. Multidimensional Impact of Cancer Risk Assessment, Genetic counseling satisfaction scale, Satisfaction with Decision Scale, Breast Cancer Heredity Knowledge Scale, Hospital Anxiety and Depression Scale/ HADS, Short Form 12 Health Survey, Cancer Worry Scale/ CWS) targeting on psychological distress, cancer worry, patient knowledge and patient satisfaction with genetic counselling and decisions by means of an anonymous mail survey. Subsequent decisions for vs. against genetic testing and if eligible, for surveillance vs. prophylactic surgery were also assessed. A reference sample of BC survivors was recruited at the outpatient unit.

Results: An overall sample of 137 counselees was included in the analysis (67.9% decided to undergo genetic testing for a HCPS, 22.6% decided not to be tested, 9.5% were still uncertain about their decision). 22.6% of counsellees experienced clinically relevant levels of anxiety and 9.8% scored above the cut-off for clinically relevant depression according to the HADS. Mean CWS score was 11 (SD 3.6, 3-24). Counsellees did not differ from breast cancer survivors regarding anxiety and depression according to the HADS (depression: p<0.5). Mean patient satisfaction with decisions amounted to 25.4 (SD 5.78, min. 4 to max. 30); a mean satisfaction with counselling of 25 (5.4) was observed. Less overall satisfaction with genetic counselling (β=0.445, t=5.552, p=0.000) and lower certainty about decision for/ against genetic testing after counselling (β=-0.169, t=-2.105, p=0.037) were highly predictive for lower long-term patient satisfaction with decisions.

Conclusion: Our results indicate that genetic counselling for BOC has no overall deleterious psychosocial consequences in long-term. Levels of depression and anxiety were comparable to those of the general population, while distress levels did not differ from those of breast cancer survivors without a hereditary BOC predisposition. The overall satisfaction with counselling as well as the certainty with decisions on testing and related medical interventions are highly predictive for the long-term satisfaction with decisions. Hence, genetic counselling should focus on supporting counsellees in forming clear decisions and include identifying counsellees with increased cared needs in this regard by means of PRO assessment in follow-up.

Citation Format: Hubalek M, Sztankay M, Meraner V, Martini C, Sperner-Unterweger B, Weber I, Morscher R, Zschocke J, Egle D, Dünser M, Oberguggenberger A. Long-term psychosocial consequences and counsellees' satisfaction after genetic counselling for hereditary breast- and ovarian cancer - A patient reported outcome study. [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 P2-09-22.

Abstract P1-11-02: Psychological morbidity in breast cancer survivors: Prevalence rates and determinants

Background: The number of breast cancer survivors (BCS) is steadily increasing due to improved treatment options, early detection and younger age at diagnosis. Thus, it is increasingly important to determine and better understand the psychological outcome following a cancer diagnosis and treatment in long-term. This might contribute to meeting the long-term health care demands of cancer survivors. We aimed at investigating levels and determinants of anxiety and depression (AD) in BCS.

Patients and Methods: We included BCS with a non-metastatic disease in the stage of after-care. AD was determined as part of a cross-sectional, comprehensive patient reported outcome (PRO) assessment (incl. Functional Assessment of Cancer Therapy-G/+B/+ES, Eating Disorder Examination-Questionnaire, Sexual Activity Questionnaire and Body Image Scale) using the Hospital Anxiety and Depression Scale (HADS). Prevalence rates of AD and sample characteristics are presented descriptively using percentages, means and standard deviations. Predictors of anxiety and depression are identified by means of regression analysis.

Results: A final sample of 743 breast cancer survivors who were on average 2.9 years post diagnosis (range: 0.1-11.3 years) participated in the study. Mean patient age was 56.4a (SD 11.5a), 2/3 of patients were postmenopausal. 22.5% of patients reported clinically relevant levels of anxiety and 11.2% of depression. Older age (β=0.012, t=2.53, p<0.05), higher endocrine symptoms (β=-0.037, t=-8.89, p<0.01) and reduced functional well-being (β=-0.034, t=-7.73, p<0.01) were predictive for anxiety and depression in the regression model. The model explained 39.3% of the variance of anxiety and depression.

Conclusion: A distinct proportion of BCS report clinically relevant, long-term psychological morbidity. Especially older BCS, experiencing higher levels of endocrine symptoms and reduced functional well-being, seem to be at risk for psychological morbidity. A routine PRO-screening for psychological morbidity including the assessment of associated risk factors in this patient population might contribute to the identification of those women in need for psychological/ psychiatric treatment and in conjunction, improve cancer care.

Citation Format: Hubalek M, Sztankay M, Oberguggenberger A, Meraner V, Egle D, Mangweth-Matzek B, Beer B, Huber N, Sperner-Unterweger B. Psychological morbidity in breast cancer survivors: Prevalence rates and determinants. [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 P1-11-02.

Abstract P4-14-11: Efficacy and cardiac safety in neoadjuvant treatment of Her2 positive breast cancer with concomitant nonpegylated liposomal doxorubicin, docetaxel and dual blockade with trastuzumab and pertuzumab: A retrospective analysis

Background: Approval to pertuzumab as part of a complete treatment regimen for patients with early stage breast cancer (EBC) before surgery (neoadjuvant setting) was granted by the FDA in September 2013. Since then, the relevance of neoadjuvant treatment in Her2 overexpressing breast cancer has increased considerably. This for instance has been emphasized by the results of the Neosphere Study, in which dual blockade of Her2 was combined with docetaxel as chemotherapy backbone and resulted in favorable pCR rates.

But it is likely, that anthracyclines could play an important role in enhancing the effectiveness of the above mentioned treatment. However, there is only little data about the cardiac safety of this combination. The use of liposomal doxorubicin might be a valuable alternative with low cardiotoxicity, as it has been shown in comparable publications without the use of pertuzumab. Therefore we report pCR-rate and cardiac safety of a single arm, retrospective, multicenter analysis of neoadjuvant treatment for Her2 positive EBC with liposomal doxorubicin, docetaxel, trastuzumab and pertuzumab.

Methods: In this study 42 women with Her2 positive EBC were investigated in 4 oncological departments in Austria. 41 patients were treated with liposomal doxorubicin (50 mg/m2), docetaxel (75 mg/m2) concurrent with trastuzumab and pertuzumab in standard dosage for 6 cycles as neoadjuvant therapy. One patient refused to receive a chemotherapy but agreed to be treated with combined antibody therapy alone. All patients were free of cardiovascular disease and had a left ventricular ejection fraction (LVEF) of ≥ 50%. Cardiac function was measured by LVEF and was examined at regular intervals (cycles 0-3, cycle 6, FU). Clinical response was evaluated by diagnostic breast imaging after cycles 3 and 6. All patients underwent surgery after neoadjuvant chemotherapy. The absence of any residual invasive cancer in the breast and axilla was defined as pathological complete response (pCR). Median follow up was 1.3 years.

Results: Median age of the patients was 49 years. After 6 cycles of treatment the pCR rate was 76.2%. In this cohort a negative estrogen-and/or progesteron receptor was predictive for pCR (p<0.001). These patients achieved pCR in 95.2%. The antibody only treatment in one case also resulted in a pCR. No patient progressed during treatment. Only one of the patients (2,4%) suffered symptomatic heart failure after surgery. The patient initially presented with an LVEF of 16%.

Conclusions: In this multicenter analysis we observed a considerably high rate of pCR in HER2-positive EBC treated with liposomal doxorubicin, docetaxel, trastuzumab and pertuzumab. Especially the group of hormone receptor negative patients showed a remarkable response rate. The addition of liposomal doxorubicin entails a very favorable cardiotoxicity profile. This regimen is a safe treatment option in patients with HER-2 positive breast cancer.

Citation Format: Egle D, Hubalek M, Hager C, Poyßl C, Lang A, Jäger T, Volgger B, Abdel-Azim S, Tiechl J, Angerer J, Marth C. Efficacy and cardiac safety in neoadjuvant treatment of Her2 positive breast cancer with concomitant nonpegylated liposomal doxorubicin, docetaxel and dual blockade with trastuzumab and pertuzumab: A retrospective analysis. [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 P4-14-11.

Appearance of the fetal posterior fossa at 11 + 3 to 13 + 6 gestational weeks on transabdominal ultrasound examination

OBJECTIVES

To describe the sonographic appearance of the structures of the posterior cranial fossa in fetuses at 11 + 3 to 13 + 6 weeks of pregnancy and to determine whether abnormal findings of the brain and spine can be detected by sonography at this time.

METHODS

This was a prospective study including 692 fetuses whose mothers attended Innsbruck Medical University Hospital for first-trimester sonography. In 3% (n = 21) of cases, measurement was prevented by fetal position. Of the remaining 671 cases, in 604 there was either a normal anomaly scan at 20 weeks or delivery of a healthy child and in these cases the transcerebellar diameter (TCD) and the anteroposterior diameter of the cisterna magna (CM), measured at 11 + 3 to 13 + 6 weeks, were analyzed. In 502 fetuses, the anteroposterior diameter of the fourth ventricle (4V) was also measured. In 25 fetuses, intra- and interobserver repeatability was calculated.

RESULTS

We observed a linear correlation between crown-rump length (CRL) and CM (CM = 0.0536 × CRL - 1.4701; R2 = 0.688), TCD (TCD = 0.1482 × CRL - 1.2083; R2 = 0.701) and 4V (4V = 0.0181 × CRL + 0.9186; R2 = 0.118). In three patients with posterior fossa cysts, measurements significantly exceeded the reference values. One fetus with spina bifida had an obliterated CM and the posterior border of the 4V could not be visualized.

CONCLUSIONS

Transabdominal sonographic assessment of the posterior fossa is feasible in the first trimester. Measurements of the 4V, the CM and the TCD performed at this time are reliable. The established reference values assist in detecting fetal anomalies. However, findings must be interpreted carefully, as some supposed malformations might be merely delayed development of brain structures.

Elevated mRNA expression of CHAC1 splicing variants is associated with poor outcome for breast and ovarian cancer patients

Background:

The role of CHAC1 (cation transport regulator-like protein 1), a recently identified component of the unfolded protein response (UPR) pathway, in gynaecological cancers has not yet been characterised. Now, this work illustrates CHAC1 mRNA expression and associated clinical outcome in breast and ovarian cancer.

Methods:

The prognostic value of CHAC1 and its two transcript variants was investigated in 116 breast and 133 ovarian tissues using quantitative real-time reverse-transcriptase PCR. Subsequently, we conducted functional studies using short-interfering RNA-mediated knockdown and plasmid-mediated overexpression of CHAC1 in breast and ovarian cancer cells.

Results:

Poorly differentiated tumours exhibited higher CHAC1 mRNA expression (breast cancer: P=0.004; ovarian cancer: P=0.024). Hormone receptor-negative breast tumours and advanced-staged ovarian cancers demonstrated elevated CHAC1 mRNA expression levels (P<0.001 and P=0.026, respectively). The multivariate survival analysis showed a prognostic value of both transcript variants in breast cancer (transcript variant 1: RR_death 6.7 (2.4–18.9); P<0.001), RR_relapse 6.7 (2.1–21.3); P=0.001); (transcript variant 2: RR_death 4.9 (2.0–12.4); P<0.001), RR_relapse 8.0 (2.4–26.8); P<0.001). Ovarian cancer patients aged younger than 62.6 years with high CHAC1 mRNA expression showed poorer relapse-free- and overall-survival (P=0.030 and P=0.012, respectively). In functional studies CHAC1 knockdown suppressed cell migration, whereas ectopic overexpression opposed these effects.

Conclusion:

High CHAC1 mRNA expression could be an independent indicator for elevated risk of cancer recurrence in breast and ovarian cancer.

Impact of nuchal cord on measurement of fetal nuchal translucency thickness

OBJECTIVE

To define the impact of nuchal cord on the measurement of fetal nuchal translucency thickness (NT).

METHODS

Between December 2004 and June 2006, we examined prospectively 53 fetuses that were observed on routine first-trimester ultrasound examination between 11 + 3 and 13 + 6 weeks of gestation to have nuchal cord causing an indentation in the skin in the nuchal region. The fetuses were re-examined after a median interval of 132 min, when the cord was no longer around the neck and indentation of the skin had resolved. Various NT measurements (highest, lowest, mean) with the cord located around the neck (nuchal cord) were compared with NT measurements in the absence of nuchal cord ('true' NT) in the same fetuses. Measurements were considered to be equal when they were within mean +/- 1.96 SD, defined by our own intraobserver repeatability according to the method of Bland and Altman.

RESULTS

The mean of the largest and the smallest of six measurements in the presence of nuchal cord fell within the mean +/- 1.96 SD of our own intraobserver repeatability, i.e. gave a correct estimate of the true NT, in 80% of fetuses, while the NT was overestimated in 10% and underestimated in 10% of fetuses. The largest and the smallest of six measurements in the presence of nuchal cord gave an underestimate of the true NT in 2% of fetuses and an overestimate in 4% of fetuses, respectively.

CONCLUSION

There is a wide scattering of measurements in fetuses with nuchal cord in comparison to the same fetuses in the absence of nuchal cord. This prevents accurate prediction of the true NT, although the largest and smallest of repeat measurements with nuchal cord can allow calculation of the highest and lowest possible risks, respectively. These facts must be taken into consideration in counseling patients.

Functional granulocyte/macrophage colony stimulating factor receptor is constitutively expressed on neoplastic plasma cells and mediates tumour cell longevity

It has been shown that granulocyte/macrophage colony stimulating factor (GM-CSF) is able to support myeloma cell propagation in cooperation with interleukin (IL)-6, the major growth factor for malignant plasma cells, although the biological mechanisms involved remain unknown. Therefore we investigated (i) the expression levels of the GM-CSF receptor (GM-CSFR) constituents in three malignant plasma cell lines and in native malignant plasma cells, (ii) the ability of the receptor to mediate common signalling pathways regulating proliferation and cell survival in malignant plasma cell lines, and (iii) the effects of GM-CSF on tumour cell biology. The GM-CSFRalpha subunit was detected in the malignant plasma cell lines RPMI-8226, MC/CAR, IM-9 as well as 6/6 native myeloma cell samples derived from the bone marrow of patients with overt disease. Furthermore, GM-CSFR expression was also detected in the CD19+ fraction from 2/3 bone marrow samples and 5/8 peripheral blood samples derived from patients with malignant plasma cell disorders, but not in the CD19+ fraction of peripheral blood from healthy donors. The expressed cytokine receptor alpha-subunit was able to constitute a functional signalling complex with the ubiquitously expressed GM-CSFRbeta subunit, as demonstrated by the fact that GM-CSF induced the p21-ras/mitogen-activated protein kinase (MAPK) signalling cascade in malignant plasma cell lines. Since this signalling cascade plays an essential role in the mediation of both proliferation and cell survival, we investigated the impact of GM-CSF on these two events. Application of GM-CSF led to an increase of DNA-synthesis in MC/CAR, IM-9 and RPMI-8226 cells. Furthermore, it increased longevity of these malignant plasma cell lines by reducing the rates of spontaneous apoptosis. We conclude that (i) the functional GM-CSFR is commonly expressed on malignant plasma cells and that (ii) GM-CSF promotes the clonal expansion of myeloma cells by inhibiting spontaneous apoptosis and promoting DNA synthesis.

Analysis of a semitendinosus autograft in a rabbit model

The purpose of this study was to evaluate the histologic and biomechanical changes that occur between 12 and 52 weeks in an intraarticular, semitendinosus autograft placed through tibial and femoral drill holes in a rabbit model. The results of this study show that, in this rabbit model, the soft tissue graft maintained its biologic fixation in the osseous tunnel when stressed to failure at 1 year. The bony fixation occurred by the formation of an indirect tendon insertion, and this formation was complete by 26 weeks. At 52 weeks, large differences persisted in the strength and stiffness of the graft compared with the normal semitendinosus tendon and anterior cruciate ligament. Based on the results of this study, we support a cautious approach in returning patients to early full activity, including sports, after anterior cruciate ligament reconstruction with a semitendinosus autograft.

Ligamentous and tendinous support of the pisiform: anatomic and biomechanical study

Twenty-five formalin-preserved cadaveric wrists were dissected and the relationship of the pisotriquetral joint (PTJ) and its surrounding soft tissue structures were defined. An additional 4 fresh frozen wrists were examined in longitudinal and transverse sections. These anatomical studies showed the extensor retinaculum to have a complex insertion into the pisiform, flexor carpi ulnaris, fifth metacarpal, pisometacarpal ligament, and the abductor digiti minimi muscle. A capsuloligamentous structure on the medial aspect of the pisotriquetral joint was also identified. Biomechanical testing was performed on 12 fresh cadaver wrists and the results were compared to the anatomical findings to determine the contribution of surrounding soft tissue structures to pisotriquetral joint stability. Mechanical testing showed the soft tissues around the pisotriquetral joint to be strongest proximally and distally and weakest medially. Transection of the transverse carpal ligament resulted in increased lateral motion of the pisiform, but there was no significant decrease in stiffness. This study provides insight into the etiology of pisotriquetral joint instability and dysfunction.

Ligamentous and tendinous support of the pisiform, anatomic and biomechanical study

Twenty-five formalin preserved cadaveric wrists were dissected and the relationship of the piso-triquetral joint and its surrounding soft tissue structures were defined. An additional 4 fresh frozen wrists were examined in longitudinal and transverse sections. These anatomical studies showed the extensor retinaculum to have a complex insertion into the pisiform, flexor carpi ulnaris, fifth metacarpal, piso-metacarpal ligament, and the abductor digit minimi muscle. A capsulo-ligamentous structure on the medial aspect of the piso-triquetral joint was also identified. Bio-mechanical testing was performed on 12 fresh cadaver wrists and the results were compared to the anatomical findings to determine the contribution of surrounding soft tissue structures to piso-triquetral joint stability. Mechanical testing showed the soft tissues around the piso-triquetral joint to be strongest proximally and distally and weakest medially. Transection of the transverse carpal ligament resulted in increased lateral motion of the pisiform, but there was no significant decrease in stiffness. This study provides insight into the etiology of piso-triquetral joint instability and dysfunction.

The effects of anabolic steroids on rat tendon. An ultrastructural, biomechanical, and biochemical analysis

Forty-eight male rats were randomly separated into four groups: a control group, a group treated with anabolic steroids, a group treated with daily exercise, and a group treated with both steroids and exercise. At 6 weeks, biomechanical, ultrastructural, and biochemical testing was performed on the Achilles tendons of half of the rats in each group. The remaining rats continued in the experimental protocol, but steroid administration was discontinued. Similar testing was then performed on the remaining rats at 12 weeks. Testing showed anabolic steroids produced a stiffer tendon that absorbs less energy and fails with less elongation; tendon strength was unaffected. Effects were entirely reversible on discontinuation of the steroids. Light microscopic analysis revealed no changes in the appearance of the fibrils. No change in fibril diameter or shape was noted on electron microscopic analysis. Biochemical testing revealed no change in qualitative immunofluorescence staining with Type III collagen or fibronectin. Abuse of anabolic steroids is a widespread problem among competitive athletes; consequently, complications after their use are seen with increasing frequency. Knowledge of the effects of these drugs on tendon and the musculotendinous unit may prove helpful in counseling athletes who use anabolic steroids.

The effect of anabolic steroids on the biomechanical and histological properties of rat tendon

Twenty-four male rats were divided into four groups, with anabolic steroids and exercise as variables. Biomechanical tests and histological evaluations were performed. The results of the biomechanical tests suggested that anabolic steroids produce a stiffer tendon, which fails with less elongation. The energy at the time when the tendon failed, the toe-limit elongation, and the elongation at the time of the first failure were all affected significantly. Changes in the force at failure were not statistically significant. No alterations of structure were noted when the specimens were viewed with light microscopy. Alterations of the sizes of the collagen fibrils were noted on electron microscopy.