Trastuzumab Plus Gemcitabine-Cisplatin for Treatment-Naïve Human Epidermal Growth Factor Receptor 2-Positive Biliary Tract Adenocarcinoma: A Multicenter, Open-Label, Phase II Study (TAB)

PURPOSE

Human epidermal growth factor receptor 2 (HER2) overexpression is seen in 4%-16% of biliary tract cancers (BTCs). We aimed to evaluate the clinical activity of gemcitabine-cisplatin (GC) plus anti-HER2 antibody trastuzumab as initial treatment in HER2-positive BTCs.

METHODS

This study was an investigator-initiated, open-label, single-arm, multi-institutional, phase II trial in adult patients with HER2-positive (defined as immunohistochemistry [IHC] 3+ or IHC 2+ and fluorescent in situ hybridization-positive), treatment-naïve BTCs. The primary end point of the study was 6-month progression-free survival (PFS). Next-generation sequencing was performed on tissue samples to evaluate mutational status.

RESULTS

From March 2020 to August 2022, of the 876 screened patients, 118 (13.4%) were found to have HER2-positive status, of whom 90 were enrolled in the study. Most patients had GBC (n = 96; 96%) with two or more sites of metastatic disease (n = 70; 78%). With a median follow-up of 17.3 (95% CI, 15.22 to 19.32) months, 72 patients had disease progression with a median PFS of 7 (95% CI, 6.2 to 7.8) months. The diagnosis to event 6-month PFS rate was 75.6% (95% CI, 66.6 to 84.6). A complete or partial response was seen in 50 (55.5%) patients and 22 (24.4%) patients had stable disease as the best response to treatment, for an overall disease control rate of 80%. The presence of isolated TP53 mutations was associated with inferior PFS compared with other mutations (TERT promoter, HER2, PIK3CA, etc) or no detected mutations (6.51 v 12.02 v 10.58 months; P < .001).

CONCLUSION

The combination of GC and trastuzumab achieved its primary end point of improving PFS compared with historical data in the treatment-naïve HER2-positive BTC. Evaluating additional mutations such as TP53 and PIK3CA along with HER2 testing may help to preferentially select patients for anti-HER2 therapy in the future (Clinical Trial Registry India number: CTRI/2019/11/021955).

Study of chemical effects on L X-rays spectra of 59Pr compounds using high resolution WDXRF and EDXRF measurements

Chemical effects on L X-rays spectra of PrF3, PrCl3, PrBr3, Pr2O3, Pr6O11 and Pr2(SO4)3 compounds have been investigated from measured ILi/ILα (i = l and β6), ILj/ILβ1 (j = η, γ5 and γ1), ILk/ILγ1 (k = γ5 and η) intensity ratios using high resolution poly-chromatic WDXRF, and monochromatic excitation by 6.49 keV in vacuum (10-2 Torr) and Ag Kαβ (22.581 keV) X-rays photons in EDXRF spectrometers. The experimental results clearly exhibit significant variation in measured intensity ratios of L X-ray components of investigated compounds from pure elemental form and theoretically predicted values evaluated using different atomic parameters. Furthermore, the change in inner shell/subshells binding energy resulting from the transitions of outer shell/subshell electrons is also inferred from the shifts of order ∼0.1-0.70 eV in Ll, Lβ2 and Lγ1 components of PrF3, PrCl3, PrBr3, Pr2O3, Pr6O11 and Pr2(SO4)3 WDXRF spectra relative to pure 59Pr. The variation in intensity ratios and shift in Ll, Lβ2 and Lγ1 X-ray components of 59Pr compounds are attributed to crystal defects, structural effects and exchange interactions between core and valence electrons of different ligands attached to central 59Pr atom. The reliable experimental data would be helpful in the theoretical interpretation of standard reference data for inner-shell vacancy decay parameters used in X-ray fluorescence analysis of compound samples.

Elemental and Chemical Phase Analyses of Ras-Family Ayurvedic Medicinal Products

Fifteen Ayurvedic medicines of Ras-family (herbo-mineral-metallic preparations) from three reputed manufactures were analysed for elemental quantification and their chemical phase identification using the energy-dispersive (ED) and wavelength-dispersive (WD) X-ray fluorescence (XRF) techniques, and powder X-ray diffraction (XRD) technique, respectively. The low-Z elements C, H, N, S and O constituting a major portion of these medicines were also determined by CHNSO analyser and further used as input for XRF analyses. The elements of concern, Hg, Pb and As, are identified in different medicine products with disquiet concentration values (maximum concentration values range ~ 4-10%) and that too with substantial variations in the products from different manufacturers. These elements are identified mainly in the cinnabar (α-HgS)/metacinnabar (β-HgS), litharge (PbO) and alacranite (As₄S₄) phases in different medicines. Keeping in view the high concentration of chemicals of the Hg, Pb and As elements in the Ras-family medicines, it is vitally required to investigate their bioaccessibility and surmise the associated toxicological aspects. It is suggested that the formation of the bioaccessible toxic chemical forms of the Hg, Pb and As elements be avoided during preparation of the mineral ingredients or these soluble chemical forms be removed at suitable stage of the preparation. In view of large variations observed for the Hg, Pb and As based ingredients in the Ras family Ayurvedic medicine products from different manufacturers, adequate quality control mechanisms and production regulations are recommended.

Fabrication of thin Molybdenum backed target using rolling method

A successful attempt was made to fabricate a thin foil of natural Mo target on a thick Au backing with Indium in between to improve adhesion between the foils. Rolling at elevated temperature was considered to fabricate Mo foil while gold foil was fabricated employing conventional rolling technique. The heating of Mo foil under natural environment lead to the oxidation or carbonization on foil surface which was confirmed through Energy Dispersive X-ray Spectroscopy (EDS) measurements. Indium of thickness ∼86μg/cm² was evaporated on Mo foil to improve adhesion between Mo and Au foils. The characterization of fabricated thin Mo foil was done using the Energy Dispersive X-ray Spectroscopy (EDS) and the Scanning Electron microscope (SEM) techniques. Thickness measurement of the target (Mo-Au) was done using Energy Dispersive X-ray Fluorescence (EDXRF) technique, in the measurements the thickness of the Mo foil and of gold backing are found out to be 1.3 mg/cm² and 9 mg/cm² respectively.

Venoms classification and therapeutic uses: a narrative review

The mere glimpse of venomous animals has always terrified humans because of the devastating effects of their venoms. However, researchers across the globe have isolated therapeutically active ingredients from these venoms and continue to explore them for drug leads. These efforts lead to the discovery of therapeutic molecules that the US-FDA has approved to treat different diseases, such as hypertension (Captopril), chronic pain (Ziconotide), and diabetes (Exenatide). The main active constituents of most venoms are proteins and peptides, which gained more attention because of advancements in biotechnology and drug delivery. The utilization of newer screening approaches improved our understanding of the pharmacological complexity of venom constituents and facilitated the development of novel therapeutics. Currently, with many venom-derived peptides undergoing different phases of clinical trials, more are in pre-clinical drug development phases. This review highlights the various sources of venoms, their pharmacological actions, and the current developments in venom-based therapeutics.

Genome-scale analysis of Arabidopsis splicing-related protein kinase families reveals roles in abiotic stress adaptation

Nearly 60 - 80 % of intron-containing plant genes undergo alternative splicing in response to either stress or plant developmental cues. RNA splicing is performed by a large ribonucleoprotein complex called the spliceosome in conjunction with associated subunits such as serine arginine (SR) proteins, all of which undergo extensive phosphorylation. In plants, there are three main protein kinase families suggested to phosphorylate core spliceosome subunits and related splicing factors based on orthology to human splicing-related kinases: the SERINE/ARGININE PROTEIN KINASES (SRPK), ARABIDOPSIS FUS3 COMPLEMENT (AFC), and Pre-mRNA PROCESSING FACTOR 4 (PRP4K) protein kinases. To better define the conservation and role(s) of these kinases in plants, we performed a genome-scale analysis of the three families across photosynthetic eukaryotes, followed by extensive transcriptomic and bioinformatic analysis of all Arabidopsis thaliana SRPK, AFC, and PRP4K protein kinases to elucidate their biological functions. Unexpectedly, this revealed the existence of SRPK and AFC phylogenetic groups with distinct promoter elements and patterns of transcriptional response to abiotic stress, while PRP4Ks possess no phylogenetic sub-divisions, suggestive of functional redundancy. We also reveal splicing-related kinase families are both diel and photoperiod regulated, implicating different orthologs as discrete time-of-day RNA splicing regulators. This foundational work establishes a number of new hypotheses regarding how reversible spliceosome phosphorylation contributes to both diel plant cell regulation and abiotic stress adaptation in plants.

Genetic overlap analysis of endometriosis and asthma identifies shared loci implicating sex hormones and thyroid signalling pathways

STUDY QUESTION

Is there a shared genetic or causal association of endometriosis with asthma or what biological mechanisms may underlie their potential relationships?

SUMMARY ANSWER

Our results confirm a significant but non-causal association of endometriosis with asthma implicating shared genetic susceptibility and biological pathways in the mechanisms of the disorders, and potentially, their co-occurrence.

WHAT IS KNOWN ALREADY

Some observational studies have reported a pattern of co-occurring relationship between endometriosis and asthma; however, there is conflicting evidence and the aetiology, as well as the underlying mechanisms of the relationship, remain unclear.

STUDY DESIGN, SIZE, DURATION

We applied multiple statistical genetic approaches in the analysis of well-powered, genome-wide association study (GWAS) summary data to comprehensively assess the relationship of endometriosis with asthma. Endometriosis GWAS from the International Endogene Consortium (IEC, 17 054 cases and 191 858 controls) and asthma GWAS from the United Kingdom Biobank (UKB, 26 332 cases and 375 505 controls) were analysed. Additional asthma data from the Trans-National Asthma Genetic Consortium (TAGC, 19 954 cases and 107 715 controls) were utilized for replication testing.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We assessed single-nucleotide polymorphism (SNP)-level genetic overlap and correlation between endometriosis and asthma using SNP effect concordance analysis (SECA) and linkage disequilibrium score regression analysis (LDSC) methods, respectively. GWAS meta-analysis, colocalization (GWAS-PW), gene-based and pathway-based functional enrichment analysis methods were applied, respectively, to identify SNP loci, genomic regions, genes and biological pathways shared by endometriosis and asthma. Potential causal associations between endometriosis and asthma were assessed using Mendelian randomization (MR) methods.

MAIN RESULTS AND THE ROLE OF CHANCE

SECA revealed significant concordance of SNP risk effects across the IEC endometriosis and the UKB asthma GWAS. Also, LDSC analysis found a positive and significant genetic correlation (rG = 0.16, P = 2.01 × 10-6) between the two traits. GWAS meta-analysis of the IEC endometriosis and UKB asthma GWAS identified 14 genome-wide significant (Pmeta-analysis < 5.0 × 10-8) independent loci, five of which are putatively novel. Three of these loci were consistently replicated using TAGC asthma GWAS and reinforced in colocalization and gene-based analyses. Additional shared genomic regions were identified in the colocalization analysis. MR found no evidence of a significant causal association between endometriosis and asthma. However, combining gene-based association results across the GWAS for endometriosis and asthma, we identified 17 shared genes with a genome-wide significant Fisher's combined P-value (FCPgene) <2.73 × 10-6. Additional analyses (independent gene-based analysis) replicated evidence of gene-level genetic overlap between endometriosis and asthma. Biological mechanisms including 'thyroid hormone signalling', 'abnormality of immune system physiology', 'androgen biosynthetic process' and 'brain-derived neurotrophic factor signalling pathway', among others, were significantly enriched for endometriosis and asthma in a pathway-based analysis.

LARGE SCALE DATA

The GWAS for endometriosis data were sourced from the International Endogen Consortium (IEC) and can be accessed by contacting the consortium. The GWAS data for asthma are freely available online at Lee Lab (https://www.leelabsg.org/resources) and from the Trans-National Asthma Genetic Consortium (TAGC).

LIMITATIONS, REASONS FOR CAUTION

Given we analysed GWAS datasets from mainly European populations, our results may not be generalizable to other ancestries.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides novel insights into mechanisms underpinning endometriosis and asthma, and potentially their observed relationship. Findings support a co-occurring relationship of endometriosis with asthma largely due to shared genetic components. Agents targeting 'selective androgen receptor modulators' may be therapeutically relevant in both disorders. Moreover, SNPs, loci, genes and biological pathways identified in our study provide potential targets for further investigation in endometriosis and asthma.

STUDY FUNDING/COMPETING INTEREST(S)

National Health and Medical Research Council (NHMRC) of Australia (241,944, 339,462, 389,927, 389,875, 389,891, 389,892, 389,938, 443,036, 442,915, 442,981, 496,610, 496,739, 552,485, 552,498, 1,026,033 and 1,050,208), Wellcome Trust (awards 076113 and 085475) and the Lundbeck Foundation (R102-A9118 and R155-2014-1724). All researchers had full independence from the funders. Authors do not have any conflict of interest.

Efficacy and safety of hydroxychloroquine for managing glycemia in type-2 diabetes: A systematic review and meta-analysis

Aims:

No Cochrane meta-analysis with grading of evidence is available on use of hydroxychloroquine (HCQ) in type-2 diabetes (T2DM). This meta-analysis evaluated the efficacy and safety of HCQ in T2DM.

Methods:

Electronic databases were searched using a Boolean search strategy: ((hydroxychloroquine) OR (chloroquine*)) AND ((diabetes) OR (“diabetes mellitus”) OR (glycemia) OR (glucose) OR (insulin)) for studies evaluating hydroxychloroquine for glycemic control in T2DM. The primary outcome was a change in glycated haemoglobin (HbA1c). The secondary outcomes were changes in other glycemic/lipid parameters and adverse effects.

Results:

Data from 11 randomized controlled trials (RCTs) (3 having placebo as controls [passive controls] and 8 having anti-diabetes medications as controls [active controls]) involving 2,723 patients having a median follow-up of 24 weeks were analyzed. About 54.54% of the RCTs were of poor quality as evaluated by the Jadad scale. The performance bias and detection bias were at high risk in 63.64% of the RCTs. The HbA1c reduction with HCQ was marginally better compared to the active (mean differences [MD]-0.17% [95%, CI:-0.30–-0.04;P=0.009;I²=89%; very low certainty of evidence, VLCE]), and passive (MD-1.35% [95%CI:-2.10–-0.59;P=0.005;I²=74%]) controls. A reduction in fasting glucose (MD-16.63mg/dL[95%, CI: -25.99 – -7.28mg/dL;P<0.001;I²=97%;VLCE]) and post-prandial glucose [MD -8.41mg/dL (95%CI: -14.71 – -2.12mg/dL;P=0.009;I²=87%;VLCE]), appeared better with HCQ compared to active controls. The total adverse events (risk ratio [RR]0.93 [95% CI:0.68–1.28]; P=0.65;I²=66%) were not different with HCQ compared to the controls.

Conclusion:

The routine use of HCQ in T2DM cannot be recommended based on the current evidence.

A nationwide 16 year analysis of trends and impact of arrythmias in transplant recipients

Background

Orthotopic heart transplantation is the most effective long-term therapy for end-stage heart disease. Denervation of transplanted heart with the loss of autonomic modulation, vasculopathy, utilization of immunosuppressant drugs, and risk of allograft rejection may result in change in the prevalence of arrhythmias in transplanted hearts.

Purpose

To describe the trends, distribution and the clinical impact of arrhythmias in transplanted hearts in a large nationwide population.

Methods

We queried the National Inpatient Sample with administrative codes. Cardiac transplant patients were identified using procedure ICD-9-CM codes 37.5 and 33.6. Common arrhythmias were extracted using appropriate validated ICD-9-CM codes. Statistical Analysis System (SAS) version 9.4 was used for analysis of data.

Results

There was a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States and 16342 (54.4%) of these had arrhythmias. The prevalence of total arrhythmias increased from 53.6% (n=1,158) in 1999 to 67.3% (n=1,575) in 2014. The most common arrhythmia was atrial fibrillation (26.83%) followed by ventricular tachycardia (22.86%) and the prevalence of individual arrhythmias is as shown in Figure 1.

Cardiogenic shock was higher in transplanted hearts with arrhythmias when compared with patients without arrhythmias (25.96% vs 18.18%; p&lt;0.001). Transplant recipients with arrhythmias were also associated with an increased use of mechanical circulatory device (18.22% vs 12.67%, p&lt;0.001). The use of implantable cardiac defibrillators and permanent pacemaker was also higher in the arrhythmia group (2.19% vs 0.63% and 40.43% vs 30.24% respectively, p&lt;0.0001). However, there was no significant difference in inpatient mortality between transplant recipients with arrhythmias and without arrhythmias (7.72% vs 6.90%, p=0.225). Further, there was no significant difference in frequency of strokes between the groups (4.98% vs 5.08%; p=0.857).

The total hospital cost when adjusted for inflation was significantly higher in the arrhythmic patients, with an average cost of about $570,415±9,590 vs $439,707±8362 in patients without arrhythmias (p&lt;0.0001). The mean length of hospitalization was 44.2±0.8 days in patients with arrhythmias compared to 33.9±0.8 days in patients without arrhythmias (p&lt;0.0001).

Conclusion

A significant proportion of patients with heart transplant have cardiac arrhythmias and are associated with worse in-hospital outcomes of cardiogenic shock, increased length of stay, and cost of hospitalization. However, they are not associated with worse inpatient mortality.

Funding Acknowledgement

Type of funding source: None

A nationwide 16-year study of the trends, burden and impact of atrial fibrillation in cardiac amyloidosis

Background

Cardiac amyloidosis (CA) remains an underdiagnosed entity. Atrial fibrillation (AF) is common in patients with CA, likely owing to direct amyloid deposition in the left atrium. However, the prevalence of AF in CA and its association with in-hospital outcomes has not been studied in large populations.

Purpose

Our aim was to study the trends, baseline characteristics, and clinical impact of AF in patients with CA in the United States using the Healthcare Cost and Utilization Project (HCUP) National) Inpatient Sample (NIS) from 1999 to 2014.

Methods

We queried the NIS and identified CA using ICD-9-CM codes 277.39 and 425.7. AF in CA patients was identified using the ICD-9-CM code of 427.31. Statistical Analysis System (SAS) 9.4 was used for analysis of data.

Results

There were a total of 145,920 CA hospitalizations between 1999 and 2014 in the United States, of which 37,070 (25.4%) had AF. The prevalence of AF remained consistent from 27.5% in 1999 to 27.4% in 2014.

The mean age of patients with AF was 72.9±28.2 years and for patients without AF was 67±31.9 years (p&lt;0.0001). The majority of the patients with AF were male (60.3%) and the study group was predominantly white (62.8% in patients with AF and 56.4% in patients without AF). CA patients with AF suffered more from thyroid-related disease (22.5% vs 16.1%), heart failure (62.9% vs 36.5%) and renal failure (34.7% vs 30.5%) and less from hypertension (29.3% vs 34.0%) and diabetes mellitus (23.2% vs 25.2%) (p&lt;0.0001). There was no significant difference in the Charlson comorbidity score between the groups.

Inpatient mortality was significantly higher in CA patients with AF (10.4% vs 6.5%, p&lt;0.001). However, in-patient mortality has been decreasing over the years from 10.3% in 1999 to 7.6% in 2014. Furthermore, cardiogenic shock was significantly higher in CA patients with AF (2.1% vs 1.2%, p&lt;0.001), yet the use of mechanical circulatory support was not significantly different between the groups (0.42% vs 0.35%, p=0.375). Pacemaker implantation was also noted to be higher in CA patients with AF compared to patients without AF (2.8% vs 1.2%, p&lt;0.0001).

There was no significant difference between CA patients with and without AF in mean cost of hospitalization ($58222±10752 vs $57695±545, p=0.081) or length of stay (7.9±0.1 vs 7.7±0.1 days, p=0.7089).

Conclusion

CA with atrial fibrillation is a well-recognized entity, and our large scale retrospective analysis found significant association with worse in-hospital outcomes and cardiogenic shock. Interestingly, trend of in-patient mortality in CA has been decreasing over the years, likely owing to improved imaging modalities for diagnosis. Optimal management of AF in CA is imperative to improve outcomes in this population.

Funding Acknowledgement

Type of funding source: None

Genome-wide gene expression in a pharmacological hormonal transition model and its relation to depressive symptoms

OBJECTIVES

Sensitivity to sex-steroid hormone fluctuations may increase risk for perinatal depression. We aimed to identify genome-wide biological profiles in women demonstrating sensitivity to pharmacological sex-hormone manipulation with gonadotrophin-releasing hormone agonist (GnRHa).

METHODS

Longitudinal gene expression (Illumina Human HT12.v4) and DNA methylation data (Infinium HumanMethylation450K BeadChip) from 60 women (30 GnRHa, 30 placebo) were generated (Trial ID: NCT02661789). Differences between baseline and two follow-up points (initial stimulation- and subsequent early suppression phase) in the biphasic ovarian hormone response to GnRHa were assessed using linear mixed effects models.

RESULTS

Genome-wide analysis revealed 588 probes differentially expressed from GnRHa intervention to first stimulatory phase follow-up (intervention group × time) after 10% fdr multiple testing correction. Of these, 54% genes were also significantly associated with estradiol changes over time (proxy for GnRHa response magnitude), 9.5% were associated with changes in depressive symptoms, and 38% were associated with changes in neocortical serotonin transporter binding. The genes were implicated in TGF beta signaling, adipogenesis, regulation of actin cytoskeleton, and focal adhesion pathways and enriched for DNA methylation changes (P = 0.006).

CONCLUSIONS

These findings point toward an altered peripheral blood transcriptomic landscape in a pharmacological model of sex-hormone-induced depressive symptoms.

Evaluation of positional accuracy of the Varian's exact-arm and retractable-arm support electronic portal imaging device using intensity-modulated radiotherapy graticule phantom

Purpose

The aim of the present study was to compare the positional accuracy of varian's exact-arm (E-arm) and retractable-arm (R-arm) supporting electronic portal imaging device (EPID) systems (amorphous silicon flat-panel detector) using the intensity-modulated radiotherapy (IMRT) graticule phantom.

Materials and Methods

The known shifts of 0.5, 1.0, and 1.5 cm were introduced to the given phantom in longitudinal, lateral, and vertical directions, respectively, with respect to treatment couch of medical linear accelerator. The experiment was repeated for different gantry angle and varying source to imager distances (SIDs). The images were acquired for each shift at varying SIDs and beam orientations for both EPID supporting systems. The corresponding shifts obtained from treatment planning system (TPS) were recorded and compared.

Results

The known (expected) and observed (recorded from TPS) shifts obtained for different beam angles (namely, 0°, 90°, 180°, and 270° for anterior, left lateral, posterior, and right-lateral portal images, respectively) in the longitudinal, lateral, and vertical direction at varying SID were compared. The maximum shift in the observed value from the expected one was 3 and 2 mm, respectively, out of the all beam configuration for R-arm and E-arm. These shifts were randomly observed for all imager position and beam orientation.

Conclusion

The IMRT graticule phantom is an effective tool to check the mechanical characteristic and consistency of different EPID supporting arms. The effect of EPID sag due to gravity (gantry and treatment couch) was not significant for detection of shift in patient's position. The E-arm support EPID has better mechanical stability and accuracy in detection of patient's position than that of R-arm.

Abstract P5-13-08: Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients

Introduction

Preoperative chemotherapy can demonstrate an individual's response to the chemotherapeutic regimen by comparing the amount of cancer at presentation to the amount remaining after treatment. Multiple previous studies have demonstrated that the amount of residual cancer, or final pathologic stage, is a better indicator of prognosis than the initial stage at presentation.

Tumor infiltrating lymphocytes have been recognized in breast cancer, and when found concentrated in breast cancer specimens, have been associated with a good prognosis. Breast cancer is not only a heterogeneous disease, but also displays varied presentation and behavior in patients of different race/ethnicities.

This study was performed to evaluate factors which predict response to chemotherapy. The effectiveness of different chemotherapeutic regimens, the effect of breast cancer subtype, and tumor infiltrating lymphocytes (TILs) were evaluated in our racial/ethnic minority population.

Methods

All patients at the safety net institution in Phoenix, AZ who underwent preoperative chemotherapy from 2002 to 2017 and had tissue available for evaluation were included in the study. Response to chemotherapy regimen was recorded. Pathologic complete response (pCR) was defined as no invasive cancer in the breast and lymph nodes in the final pathologic specimen. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal subtypes were classified based on Ki67 (&gt;15%) and/or PR (&lt;20%) for Luminal B. Her2 subtype was defined as Her2 IHC 3+ or Her2 FISH amplified. Triple negative breast cancer (TNBC) was defined as ER and PR (&lt;5%) and Her2 negative. TILs concentration was determined from fixed formalin paraffin embedded (FFPE) core needle biopsy specimens.

Results

A total of 259 patients were included in the study. The mean age was 45 years. 80% of the population were racial/ethnic minorities. The vast majority (94%) were underinsured or uninsured, with 75% uninsured. The mean clinical tumor size at presentation was 6cm. 52% presented at clinical stage 2 while 48% presented at clinical stage 3. The overall pCR rate was 32%. pCR rate was impacted by breast cancer subtype with TNBC 52% and Her2 38% showing a better response to chemotherapy, while Luminal B was 16% and Luminal A 2% (p &lt; 0.05). In TNBC, chemotherapy regimens with anthracycline and docetaxel may have improved efficacy with pCR of 56% (p = 0.05). In the subgroup available for TIL evaluation, breast cancer subtype appeared to show similar importance with pathologic complete response rates of TNBC 50%, Her2 44%, Luminal B 12%, and Luminal A 0%. TIL appeared to affect the likelihood of pCR. When TIL were less than 5% the pCR rate was 16% compared to when there were TIL of at least 5% or more the pCR rate was 41% (p &lt; 0.05).

Conclusions

In our racial/ethnic minority population, breast cancer subtype and chemotherapy regimen did affect likelihood of pathologic complete response. Tumor infiltrating lymphocyte concentration as low as 5% may indicate a higher likelihood of pathologic complete response and could be used as an additional factor in the evaluation of patients for preoperative therapy.

Citation Format: Komenaka IK, Cocco D, Huliyar R, Hsu C-H, Martinez ME, Gago M, Nodora J, Mehta D, Caruso DM. Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-08.

Blind esophageal brushing offers a safe and accurate method to monitor inflammation in children and young adults with eosinophilic esophagitis

Patients with eosinophilic esophagitis (EoE) require frequent evaluation of mucosal inflammation via endoscopy. Instead of endoscopy, mucosal evaluation in adults with esophageal cancer and candidiasis is achieved using a cytology brush inserted through a nasogastric tube (NGT). We conducted a prospective cross-sectional study in children and young adults scheduled for routine esophagogastroduodenoscopy (EGD) where in Phase 1, we performed esophageal brushing through the endoscope under direct visualization and in Phase 2, we inserted the brush through a Cortrak® NGT prior to endoscopy. Eosinophil-derived neurotoxin (EDN) measured by ELISA in the samples extracted from brushes was validated as the sensitive biomarker. We collected 209 esophageal brushing samples from 94 patients and we found that EDN in brushing samples collected via EGD or NGT was significantly higher in patients having active EoE (n = 81, mean EDN 381 mcg/mL) compared with patients having gastroesophageal reflux disease (n = 31, mean EDN 1.9 mcg/mL, P = 0.003), EoE in remission (n = 47, mean EDN 3.7 mcg/mL, P = 0.003), or no disease (n = 50, mean EDN 1.1 mcg/mL, P = 0.003). EDN at a concentration of ≥10 mcg/mL of brushing sample was found to accurately detect active EoE. NGT brushing did not cause any significant adverse effects. We concluded that blind esophageal brushing using an NGT is a fast, less invasive, safe, and well-tolerated technique compared with EGD to detect and monitor EoE inflammation using EDN as the sensitive biomarker.

Cross-disorder risk gene CACNA1C differentially modulates susceptibility to psychiatric disorders during development and adulthood

Single-nucleotide polymorphisms (SNPs) in CACNA1C, the α1C subunit of the voltage-gated L-type calcium channel Cav1.2, rank among the most consistent and replicable genetics findings in psychiatry and have been associated with schizophrenia, bipolar disorder and major depression. However, genetic variants of complex diseases often only confer a marginal increase in disease risk, which is additionally influenced by the environment. Here we show that embryonic deletion of Cacna1c in forebrain glutamatergic neurons promotes the manifestation of endophenotypes related to psychiatric disorders including cognitive decline, impaired synaptic plasticity, reduced sociability, hyperactivity and increased anxiety. Additional analyses revealed that depletion of Cacna1c during embryonic development also increases the susceptibility to chronic stress, which suggest that Cav1.2 interacts with the environment to shape disease vulnerability. Remarkably, this was not observed when Cacna1c was deleted in glutamatergic neurons during adulthood, where the later deletion even improved cognitive flexibility, strengthened synaptic plasticity and induced stress resilience. In a parallel gene × environment design in humans, we additionally demonstrate that SNPs in CACNA1C significantly interact with adverse life events to alter the risk to develop symptoms of psychiatric disorders. Overall, our results further validate Cacna1c as a cross-disorder risk gene in mice and humans, and additionally suggest a differential role for Cav1.2 during development and adulthood in shaping cognition, sociability, emotional behavior and stress susceptibility. This may prompt the consideration for pharmacological manipulation of Cav1.2 in neuropsychiatric disorders with developmental and/or stress-related origins.

Sustained virological response to ombitasvir/paritaprevir/ritonavir and dasabuvir treatment for hepatitis C: Real-world data from a large healthcare provider

Treatment with ombitasvir/paritaprevir/ritonavir and dasabuvir, with or without ribavirin (OPrD ± RBV), was the first interferon-free direct-acting antiviral for hepatitis C virus (HCV) introduced to Israel's national basket of health services in February 2015. Patients with HCV genotype 1 (GT1) and advanced fibrosis (F3-F4) were eligible for treatment in 2015. This study aimed to characterize patients initiating OPrD ± RBV and assess sustained virological response (SVR). A retrospective cohort study was performed using the database of Maccabi Healthcare Services (MHS), a 2-million-member health plan in Israel. The study population included adults who initiated OPrD ± RBV through December 2015 per health basket criteria. A gap in medication fills (>14 days between a fill's run-out and the next fill) was used to estimate adherence. SVR was defined by the viral tests at least 12-week post-treatment. The study population consisted of 403 patients (56.3% male), with a mean age of 60.7 years (SD 11.0). Overall, 71.0% were naïve to prior HCV treatment, and 95.6% were treated with a 12-week regimen. A total of 348 patients (86.4%) completed the regimen in the usual time frame (highly adherent), whereas 8.2% completed with a gap, and 4.7% purchased less than the recommended dose. SVR rates overall and among highly adherent patients were 395/403 (98.0%; 95% CI 96.1-99.1) and 346/348 (99.4%; 95% CI 97.9-99.9), respectively. GT1b patients on 12-week regimens attained SVR rates of 194/196 (fibrosis F3) and 170/176 (cirrhosis). After a first year of provision of OPrD ± RBV with good adherence, high SVR rates were achieved in various patient subgroups and comorbidities.

Genomewide DNA methylation analysis in combat veterans reveals a novel locus for PTSD

OBJECTIVE

Epigenetic modifications such as DNA methylation may play a key role in the aetiology and serve as biomarkers for post-traumatic stress disorder (PTSD). We performed a genomewide analysis to identify genes whose DNA methylation levels are associated with PTSD.

METHOD

A total of 211 individuals comprising Australian male Vietnam War veterans (n = 96) and males from a general population belonging to the Grady Trauma Project (n = 115) were included. Genomewide DNA methylation was performed from peripheral blood using the Illumina arrays. Data analysis was performed using generalized linear regression models.

RESULTS

Differential DNA methylation of 17 previously reported PTSD candidate genes was associated with PTSD symptom severity. Genomewide analyses revealed CpG sites spanning BRSK1, LCN8, NFG and DOCK2 genes were associated with PTSD symptom severity. We replicated the findings of DOCK2 in an independent cohort. Pathway analysis revealed that among the associated genes, genes within actin cytoskeleton and focal adhesion molecular pathways were enriched.

CONCLUSION

These data highlight the role of DNA methylation as biomarkers of PTSD. The results support the role of previous candidates and uncover novel genes associated with PTSD, such as DOCK2. This study contributes to our understanding of the biological underpinnings of PTSD.

Abstract P6-12-06: Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population

Background: Although the Hispanic population is among the fastest growing in the United States, however, less is known about them then other populations. Breast cancer in different racial/ethnic populations display different behaviors. The current study was performed to examine response to preoperative chemotherapy regimen and by breast cancer subtype in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who underwent preoperative chemotherapy from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Response to chemotherapy regimen was recorded. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal B subtype was classified based on Ki67 (&gt;15%) and PR (&lt;20%).

Results: The average age of the 133 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). The average size of the cancers at presentation was 5cm. Overall 86% of patients had a clinical response to preoperative chemotherapy and 35% had pathologic complete response (pCR). AC and TC regimens had the lowest rate of pCR at 16%. AC/T (every 3 week and weekly) had similar rates of pCR 23% and 29%, while dose dense regimens showed pCR 40%. Herceptin containing regimens had pCR 57%. 7 patients received TAC and 71% had pCR.

By subtype, Luminal A and B patients had low rates of pCR 9% and 14% respectively. Luminal B patients did benefit from preoperative chemotherapy as 86% of patients who were not candidates for breast conservation at presentation were able to undergo lumpectomy after preoperative chemotherapy. Her2 subtype patients who got Herceptin had pCR 57%. Triple negative patients had pCR 54%.

Conclusions: In this underinsured, Hispanic population who presented at advanced stages, differences in response to preoperative chemotherapy were seen based on breast cancer subtype. Differences were also seen based on chemotherapy regimen. TAC maybe a particularly effective regimen in triple negative Hispanic women.

Citation Format: Mehta D, Winton L, Walters J, Hsu C-H, Nodora J, Martinez ME, Bouton M, Komenaka IK. Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population. [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 P6-12-06.

Abstract P6-12-07: The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography

Background: Despite prospective clinical trials demonstrating the safety and effectiveness of preoperative chemotherapy for nearly 2 decades, it may still be underutilized in underserved, uninsured populations most likely to present with advanced cancers. The current study was performed to evaluate the effect of preoperative chemotherapy (PC) in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who presented at clinical stage 2 or higher and were treated from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Surgical outcomes were evaluated. Margin status was determined for those who underwent breast conservation.

Results: The average age of the 266 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). Only 24% of patients underwent screening mammography. 133 underwent PC and 133 had primary operations. Patients who underwent PC presented with larger cancers (5cm vs 3.5cm, p &lt; 0.001). 96% of patients in PC group were not candidates for lumpectomy at presentation. However, lumpectomy was performed more often in those who underwent PC (75% vs. 57%, p = 0.01). Re-excision for margins were necessary less often in those who underwent PC (10.3% vs 27%, p = 0.01). Patients who underwent PC were also less likely to require an ALND (33% vs 47%, p = 0.04). Despite presentation at higher average clinical stage in patients who underwent PC, at average follow up of 52 months, risk of IBTR and risk of regional recurrence were similar in the PC and no-PC groups (IBTR: 4.4% vs 3%, p = 0.99 and Regional: 1.5% vs. 1.5%, p = 0.99). Breast cancer specific survival was 86.5% in the PC group compared to 84% in the no-PC group (p = 0.68). Patients in the no-PC group were less likely to comply with recommended chemotherapy.Conclusions: In this underinsured, Hispanic population who did not use screening mammography, preoperative chemotherapy allowed many women to undergo breast conservation, undergo fewer operations, and were less likely to require ALND. Risk of local and regional recurrence is low in these patients and comparable to those who underwent primary operation.

Citation Format: Komenaka IK, Djenic B, Walters J, Hsu C-H, Nodora JN, Martinez ME, Bouton M, Mehta D. The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography. [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 P6-12-07.

FKBP51 inhibits GSK3β and augments the effects of distinct psychotropic medications

Psychotropic medications target glycogen synthase kinase 3β (GSK3β), but the functional integration with other factors relevant for drug efficacy is poorly understood. We discovered that the suggested psychiatric risk factor FK506 binding protein 51 (FKBP51) increases phosphorylation of GSK3β at serine 9 (pGSK3β(S9)). FKBP51 associates with GSK3β mainly through its FK1 domain; furthermore, it also changes GSK3β's heterocomplex assembly by associating with the phosphatase PP2A and the kinase cyclin-dependent kinase 5. FKBP51 acts through GSK3β on the downstream targets Tau, β-catenin and T-cell factor/lymphoid enhancing factor (TCF/LEF). Lithium and the antidepressant (AD) paroxetine (PAR) functionally synergize with FKBP51, as revealed by reporter gene and protein association analyses. Deletion of FKBP51 blunted the PAR- or lithium-induced increase in pGSK3β(S9) in cells and mice and attenuated the behavioral effects of lithium treatment. Clinical improvement in depressive patients was predicted by baseline GSK3β pathway activity and by pGSK3β(S9) reactivity to ex vivo treatment of peripheral blood mononuclear lymphocytes with lithium or PAR. In sum, FKBP51-directed GSK3β activity contributes to the action of psychotropic medications. Components of the FKBP51-GSK3β pathway may be useful as biomarkers predicting AD response and as targets for the development of novel ADs.

Management and outcomes of single subsegmental pulmonary embolus: a retrospective audit at North Shore Hospital, New Zealand

BACKGROUND

It is unknown whether filling defects in subsegmental arteries on multidetector computed tomography pulmonary angiography correlate with clinically relevant subsegmental pulmonary embolism (PE) on pulmonary angiography. Current guidelines do not differentiate between PE in segmental and subsegmental vessels, and many patients receive at least 3 months anticoagulation. The strategy employed at North Shore Hospital in haemodynamically stable patients with single subsegmental PE is to perform bilateral lower leg compression ultrasound (CUS). Anticoagulation is withheld if CUS is negative; a bilateral CUS is repeated in 7-10 days.

AIM

The aim of this retrospective audit was to ensure our current management strategy is safe.

METHODS

All diagnoses of single subsegmental PE between June 2005 and June 2013 were included. The primary outcome was the rate of venous thromboembolism (VTE) recurrence within 3 months of single subsegmental PE diagnosis. Secondary outcomes were rates of major/minor bleeding and all-cause mortality.

RESULTS

Thirty-two patients were included - 20 were treated with anticoagulation; 12 were managed with observation/serial bilateral lower limb CUS. None of the patients in either group had VTE recurrence by 3 months. No bleeding episodes were observed in the observation group; there was a 10% major bleeding rate (n = 2) in the treatment group. One death occurred in each group, neither of which was attributed to VTE.

CONCLUSION

Withholding anticoagulation in patients with single subsegmental PE and negative serial bilateral CUS appears to be a safe and effective management strategy, with a low risk of VTE recurrence.

Early predictive biomarkers for postpartum depression point to a role for estrogen receptor signaling

BACKGROUND

Postpartum depression (PPD) affects approximately 13% of women and has a negative impact on mother and infant, hence reliable biological tests for early detection of PPD are essential. We aimed to identify robust predictive biomarkers for PPD using peripheral blood gene expression profiles in a hypothesis-free genome-wide study in a high-risk, longitudinal cohort.

METHOD

We performed a genome-wide association study in a longitudinal discovery cohort comprising 62 women with psychopathology. Gene expression and hormones were measured in the first and third pregnancy trimesters and early postpartum (201 samples). The replication cohort comprised 24 women with third pregnancy trimester gene expression measures. Gene expression was measured on Illumina-Human HT12 v4 microarrays. Plasma estradiol and estriol were measured. Statistical analysis was performed in R.

RESULTS

We identified 116 transcripts differentially expressed between the PPD and euthymic women during the third trimester that allowed prediction of PPD with an accuracy of 88% in both discovery and replication cohorts. Within these transcripts, significant enrichment of transcripts implicated that estrogen signaling was observed and such enrichment was also evident when analysing published gene expression data predicting PPD from a non-risk cohort. While plasma estrogen levels were not different across groups, women with PPD displayed an increased sensitivity to estrogen signaling, confirming the previously proposed hypothesis of increased sex-steroid sensitivity as a susceptibility factor for PPD.

CONCLUSIONS

These results suggest that PPD can be robustly predicted in currently euthymic women as early as the third trimester and these findings have implications for predictive testing of high-risk women and prevention and treatment for PPD.

Potential energy landscape of the two-dimensional XY model: higher-index stationary points

The application of numerical techniques to the study of energy landscapes of large systems relies on sufficient sampling of the stationary points. Since the number of stationary points is believed to grow exponentially with system size, we can only sample a small fraction. We investigate the interplay between this restricted sample size and the physical features of the potential energy landscape for the two-dimensional XY model in the absence of disorder with up to N = 100 spins. Using an eigenvector-following technique, we numerically compute stationary points with a given Hessian index I for all possible values of I. We investigate the number of stationary points, their energy and index distributions, and other related quantities, with particular focus on the scaling with N. The results are used to test a number of conjectures and approximate analytic results for the general properties of energy landscapes.

Fast ion surface energy loss and straggling in the surface wake fields

We have measured the stopping powers and straggling of fast, highly ionized atoms passing through thin bilayer targets made up of metals and insulators. We were surprised to find that the energy losses as well as the straggling depend on the ordering of the target and have small but significantly different values on bilayer reversal. We ascribe this newly found difference in energy loss to the surface energy loss field effect due to the differing surface wake fields as the beam exits the target in the two cases. This finding is validated with experiments using several different projectiles, velocities, and bilayer targets. Both partners of the diatomic molecular ions also display similar results. A comparison of the energy loss results with those of previous theoretical predictions for the surface wake potential for fast ions in solids supports the existence of a self-wake.

A first-in-class, first-in-human, phase I trial of p28, a non-HDM2-mediated peptide inhibitor of p53 ubiquitination in patients with advanced solid tumours

Background:

This first-in-human, phase I clinical trial of p28 (NSC745104), a 28-amino-acid fragment of the cupredoxin azurin, investigated the safety, tolerability, pharmacokinetics and preliminary activity of p28 in patients with p53⁺ metastatic solid tumours.

Methods:

A total of 15 patients were administered p28 i.v. as a short infusion three times per week for 4 weeks followed by a 2-week rest under an accelerated titration 3+3 dose escalation design until either a grade 3-related adverse event occurred or the maximum tolerated dose (MTD) was reached. Single-dose and steady-state serum pharmacokinetics were characterised. Assessments included toxicity, best objective response by RECIST 1.1 Criteria, and overall survival.

Results:

No patients exhibited any dose-limiting toxicities (DLTs), significant adverse events or exhibited an immune response (IgG) to the peptide. The No Observed Adverse Effect Level (NOAEL) and MTD were not reached. Seven patients demonstrated stable disease for 7–61 weeks, three a partial response for 44–125 weeks, and one a complete response for 139 weeks. Three patients are still alive at 158, 140, and 110 weeks post therapy completion.

Conclusion:

p28 was tolerated with no significant adverse events. An MTD was not reached. Evidence of anti-tumour activity indicates a highly favourable therapeutic index and demonstrates proof of concept for this new class of non-HDM2-mediated peptide inhibitors of p53 ubiquitination.