Transcription factor defects in inborn errors of immunity with atopy

Transcription factors (TFs) are critical components involved in regulating immune system development, maintenance, and function. Monogenic defects in certain TFs can therefore give rise to inborn errors of immunity (IEIs) with profound clinical implications ranging from infections, malignancy, and in some cases severe allergic inflammation. This review examines TF defects underlying IEIs with severe atopy as a defining clinical phenotype, including STAT3 loss-of-function, STAT6 gain-of-function, FOXP3 deficiency, and T-bet deficiency. These disorders offer valuable insights into the pathophysiology of allergic inflammation, expanding our understanding of both rare monogenic and common polygenic allergic diseases. Advances in genetic testing will likely uncover new IEIs associated with atopy, enriching our understanding of molecular pathways involved in allergic inflammation. Identification of monogenic disorders profoundly influences patient prognosis, treatment planning, and genetic counseling. Hence, the consideration of IEIs is essential for patients with severe, early-onset atopy. This review highlights the need for continued investigation into TF defects to enhance our understanding and management of allergic diseases.

Influence of germline BRCA genotype on the survival of patients with triple-negative breast cancer

The presence of BRCA pathogenic variants (PVs) in triple-negative breast cancer (TNBC) is associated with a distinctive genomic profile that makes the tumor particularly susceptible to DNA-damaging treatments. However, patients with BRCA PVs can develop treatment resistance through the appearance of reversion mutations and restored BRCA expression. As copy-number variants (CNV) could be less susceptible to reversion mutations than point mutations, we hypothesize that carriers of BRCA CNVs may have improved survival after treatment compared to carriers of other BRCA PVs or BRCA wild-type. Women diagnosed with stage I-III TNBC at ≤50 years at a cancer center in Mexico City were screened for BRCA PVs using a recurrent PV assay (HISPANEL; 77% sensitivity). The recurrence-free (RFS) and overall survival (OS) were compared according to mutational status. Among 180 women, 17 (9%) were carriers of BRCA1 ex9-12del CNV and 26 (14%) of other BRCA PVs. RFS at ten years for the whole cohort was 79.2% (95% CI 72.3-84.6%), with no significant differences according to mutational status. 10-year OS for the entire cohort was 85.3% (95%CI: 78.7-90.0%), with BRCA CNV carriers demonstrating numerically superior OS rates other PV carriers and non-carriers (100% vs. 78.6% and 84.7%; log-rank p=0.037 and p=0.051, respectively). This study suggests that BRCA1 ex9-12del CNV carriers with TNBC may have a better OS, and supports the hypothesis that the genotype of BRCA PVs may influence survival by limiting treatment resistance mediated by reversion mutations among CNV carriers.

The prevalence of BRCA1 and BRCA2 mutations among young Mexican women with triple-negative breast cancer

Various guidelines recommend that women with triple-negative breast cancer should be tested for BRCA1 mutations, but the prevalence of mutations may vary with ethnic group and with geographic region, and the optimal cutoff age for testing has not been established. We estimated the frequencies of BRCA1 and BRCA2 (BRCA) mutations among 190 women with triple-negative breast cancer, unselected for family history, diagnosed at age 50 or less at a single hospital in Mexico City. Patients were screened for 115 recurrent BRCA mutations, which have been reported previously in women of Hispanic origin, including a common large rearrangement Mexican founder mutation (BRCA1 ex9-12del). A BRCA mutation was detected in 44 of 190 patients with triple-negative breast cancer (23 %). Forty-three mutations were found in BRCA1 and one mutation was found in BRCA2. Seven different mutations accounted for 39 patients (89 % of the total mutations). The Mexican founder mutation (BRCA1 ex9-12del) was found 18 times and accounted for 41 % of all mutations detected. There is a high prevalence of BRCA1 mutations among young triple-negative breast cancer patients in Mexico. Women with triple-negative breast cancer in Mexico should be screened for mutations in BRCA1.

Legality and age influence end of life decisions in Mexican physicians

PURPOSE

To test in two groups of physicians-in-training a simplified questionnaire exploring their acceptance of Physician Assisted Death (PAD), Therapy Withdrawal upon family request (WD), and Personalized PAD (PPAD) on whether the participant would seek PAD for him/herself.

MATERIAL AND METHODS

A 4-item questionnaire was answered by 212 residents in different stages of training and grouped as beginners (1st and 3d year internal medicine residents, n = 76) and advanced (5th to 8th year residents of different internal medicine or oncology subspecialties, n = 136). The response options to the PAD and WD questions included a conditioned yes (CYes) dealing with legalization of PAD or the existence of a patient's previous written agreement to WD.

RESULTS

Beginners had significantly more Yes plus C-Yes answers than advanced for questions regarding PAD (82 vs. 55%), WD (95 vs. 75%) and PPAD (76 vs. 56%). The importance of legal aspects implied in the conditioned answers can be seen in two findings: a) A sizable 29% of participants conditioned their Yes answers for both questions whereas only 9% gave an unconditioned Yes to both. b) A cross-classification of the PAD and WD answers showed that 13% of participants reversed their No in PAD to C-Yes in WD.

CONCLUSIONS

Our simplified questionnaire operated well and was able to confirm the increase in acceptance of PAD and WD by young Mexican physicians, and the need of legislation regarding end of life decisions in our country.

Physician-assisted death. Opinions of Mexican medical students and residents

BACKGROUND AND AIMS

To explore opinions of young residents and medical students on physician-assisted death (PAD).

METHODS

A questionnaire was answered by 140 residents at the beginning of their residency and 99 third- or fourth-year medical students (46 attended religiously administered medical schools [RAMS] and 53 lay-administered medical schools [LAMS]). Main questions were agreement with PAD, therapy withdrawal (TW) and personalized PAD (PPAD) on whether participants themselves would seek help to die.

RESULTS

There were no differences of acceptance between residents and students but LAMS students had significantly higher agreement than RAMS students for PAD (68 vs. 33%), TW (79 vs. 39%) and PPAD (57 vs. 48%). LAMS students were also more willing to agree to a physician prescribe/inject a lethal drug, even if PAD were not legalized. However, legality was also an important issue, i.e., 25-58% of those unsure or opposed to PAD would reverse the decision if PAD were legalized, and 42-54% of those unwilling to TW would also reverse if written consent of the patient existed. Overall acceptance of residents and students was significantly higher than our previous study in nearly 1,000 older physicians (50 vs. 39% for PAD and 58 vs. 48% for TW).

CONCLUSIONS

PAD and TW acceptability seems to be increasing in Mexico, probably as a result of evolving social attitudes that appeared to be counteracted by a more conservative upbringing at home in our young RAMS students.

Pathologic response and disease-free survival (DFS) after neoadjuvant trastuzumab (T) for HER2+ breast cancer (BC): Results from the National Cancer Institute (NCI) of Mexico

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Background: The most accurate definition of pathologic complete response (pCR) in HER2+ BC patients (pts) receiving T-based neoadjuvant chemotherapy associated with improved DFS is controversial, particularly regarding the role of residual ductal carcinoma in situ (ypTis) and focal invasive residuals (ypT1mic). The effect of pCR on DFS in various subgroups of HER2+ BC is also uncertain. Methods: Pts with localized HER2+ BC that received T-based neoadjuvant chemotherapy at NCI between January 2007 and May 2012 were identified. We conducted an exploratory analysis of DFS in pts according to their tumor response. DFS curves were derived from Kaplan-Meier estimates and compared by log-rank test. Multivariate analysis was performed using Cox’s regression model. Results: 243 pts were included for analysis. Median follow-up was 39 months (mo). 49% of pts had no invasive and no in situ residuals at surgery (ypT0), 14.4% had ypTis/ypT1mic residuals and 36.6% had gross residual BC. DFS was significantly superior in pts with both ypT0 and ypTis/ypT1mic (no gross invasive residual BC) compared with those with gross residual disease (60.6 and 62.7 mo respectively vs. 51.6 mo, p=0.011 and 0.017). There was no difference in DFS between ypT0 and ypTis/ypT1mic pts (p=0.402). The rate of no gross invasive residual BC was significantly superior in pts with ER-PR- tumors compared with patients with ER+/PR+ tumors (69.9% vs. 56.7%, p=0.034). No gross invasive residual BC was associated with improved DFS in pts with HER2+ ER-/PR- (60.3 vs. 49.0 mo; p=0.005), as opposed to HER2+ ER+/PR+ tumors (61.0 vs. 51.6 mo; p=0.100). Multivariate analysis showed that tumor size (p=0.013) and no gross invasive residual BC (p=0.13) were associated with improved DFS in all subgroups. Conclusions: The absence of gross invasive residual BC was associated with improved DFS in pts with HER2+ BC treated with T-based neoadjuvant chemotherapy, particularly in those with HER2+ ER-/PR- BC. Our data suggest a comparable DFS in HER2+ BC patients with no gross invasive residual BC regardless of the presence or absence of both ypTis and ypT1mic disease after neoadjuvant treatment.

Predictive factors for pathologic complete response (pCR) to trastuzumab (T)-based neoadjuvant chemotherapy in HER2+ breast cancer (BC) women treated in the National Cancer Institute (NCI) of Mexico

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Background: Neoadjuvant treatment identifies subgroups of patients (pts) with different prognosis. In HER2+ BC, some tumors have been reported to be more sensitive to anti-HER2 therapy than others. We conducted an exploratory analysis in HER2+ BC women who received T-based neoadjuvant chemotherapy. Methods: Clinico-pathologic data from HER2+ BC pts who received neoadjuvant chemotherapy and T between January 2007 and May 2012 at the NCI were identified. Estrogen receptor (ER), progesterone receptor (PR) and HER2 expression were determined by immunohistochemistry and/or FISH. pCR was defined as complete absence of invasive tumor in breast and axillary nodes. Proportion differences were tested using the Chi-square test. A generalized linear model was used for multivariate analysis. Results: 243 pts received T-based neoadjuvant chemotherapy for localized HER2+ BC tumors. Median age was 49 (26-72) years. 96% had positive axillary nodes at diagnosis and median tumor size was 5.5 (1.5-20) cm. 49.4% had hormone receptor (HR) + (ER+ and/or PR+) and 50.6% HR negative (ER- and PR-) tumors. 63.4% pts achieved pCR. HR negative tumors reached significantly higher pCR rates than HR + tumors (69.9% vs. 56.7%, p=0.034). Pts with inflammatory BC (n=27) had a trend to achieve pCR less frequently than the non-inflammatory tumors (48.1% vs. 65.3%). Those who received taxane-anthracyline sequence chemotherapy (n=20) achieved pCR in 70% of the cases vs. 62.8% with anthracycline-taxane sequence. Differences among other variables (age, tumor size, nodes and HER2 positivity ++/+++) were not significant. Variables that positively influenced pCR were HR negative status (p=0.015), non-inflammatory BC (p=0.082) and chemotherapy sequence (p=0.086). Conclusions: HR negative HER2+ BC tumors were associated with higher pCR, consistent with neoadjuvant trial reports. Preclinical data suggest bi-directional crosstalk between HER2 and ER pathways, which might influence anti-HER2 agents and chemotherapy sensitivity for tumors co-expressing both receptors. New strategies are needed to overcome resistance for HER2+ HR+ BC tumors.

Impact of diabetes and hyperglycemia on outcomes in advanced breast cancer patients

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Background: Clinical experience and previous studies suggest that women with diabetes and breast cancer (BrCa) have worse outcomes than their non-diabetic counterparts. However, analysis of the contribution of diabetes to BrCa specific mortality is difficult because of the substantial mortality attributed to diabetes alone and because diabetes is commonly associated with adverse prognostic factors specific to BrCa. The purpose of this study was to examine the impact of diabetes and hyperglycemia on cancer-specific survival of patients with metastatic or recurrent BrCa. Methods: We performed a retrospective analysis of patients with advanced BrCa receiving palliative chemotherapy from 2006 to 2011 at the National Cancer Institute in Mexico, and compared breast cancer-specific mortality in diabetic and non-diabetic patients, as well as in patients that presented hyperglycemia during palliative treatment. Results: A total of 265 patients receiving palliative therapy were eligible for inclusion. Previous diagnosis or detection of diabetes at recurrence was recorded in 40 patients (15%). No difference was observed between diabetic and non-diabetic patients in terms of overall survival (OS). A statistically significant difference in OS was observed between patients without diabetes and diabetics who had hyperglycemia (p=0.003). OS in diabetic patients with proper metabolic control was shown to be superior compared to diabetics with hyperglycemia (p=0.01). Hyperglycemia was identified in 14% of non-diabetics at some point while receiving palliative treatment. For patients that experienced hyperglycemia during treatment or who had a mean glucose level > 130, either in the diabetic or non-diabetic subgroups, a worse outcome was noted compared to normoglycemic patients, with a HR of 1.5 (p=0.029) and HR of 2.04 (p=0.006) for death, respectively. Conclusions: Elevated glucose levels confer a poor outcome in diabetic and non-diabetic patients in contrast with patients with normoglycemic levels, conferring an elevated risk of death. According to these results, clinicians must monitor glucose levels during treatment for advanced BrCa disease, and should take action in order to maintain normal glucose levels.