PRAME immunohistochemistry compared to traditional FISH testing in spitzoid neoplasms and other difficult to diagnose melanocytic neoplasms

PRAME (PReferentially expressed Antigen in Melanoma) is a gene first identified in melanoma. It has been proposed as a useful marker to differentiate melanoma from benign melanocytic neoplasms. Recently genomic testing using fluorescence in situ hybridization has been used to aid in the diagnosis of difficult melanocytic neoplasms. We have compared PRAME staining to FISH testing results in 83 difficult to classify melanocytic neoplasms which showed spitzoid histologic features. A relatively low sensitivity of 29.6% and high specificity of 76.8% is seen with PRAME staining as compared to genomic testing with fluorescence in situ hybridization. This study highlights the limitations of PRAME staining in spitzoid neoplasms.

The impact of high intensity interval training in a diverse group of cancer survivors: CAPABLE, a pilot study

Purpose

Given the well-documented benefits of regular exercise to cancer survivors, current American Cancer Society guidelines recommend that patients engage in a minimum of 150 min per week of moderate-to-vigorous physical activity with a minimum of two days of strength training. However, few survivors meet this goal, particularly among minorities.

Methods

The CAPABLE study is a single-arm, pilot exercise intervention that introduced 48 cancer survivors to a high intensity interval and strength training program three days a week for 12 weeks. We evaluated the impact of this unique training method on bodyweight, % body fat, serum markers correlated with an adverse cardiometabolic profile and health-related quality of life (HRQoL). Measures were summarized at baseline and program exit. Paired t-tests were used to assess change in each of these measures over time.

Results

We observed losses in weight, body mass index, and % body fat, and glycosylated hemoglobin (HbA1c) levels over 12-weeks. There were also clinically meaningful improvements in reported overall HRQoL (FACTG total change +9.5 (95% CI, 4.6, 14.4)) and in each one of the individual domains (physical, social, emotional, and functional well-being).

Conclusions

We observed meaningful improvements in body composition, HbA1c and quality of life over 12 weeks among cancer survivors participating in a high-intensity interval training program. Future work will include a control arm for comparison and address barriers to participation and adherence which will be important in using this intervention and others like it to improve outcomes and reduce cancer health disparities.

Use of PRAME immunostaining to distinguish early melanoma in situ from benign pigmented conditions

BACKGROUND

PRAME (PReferentially expressed Antigen in MElanoma) is an antigen that shows marked overexpression in melanoma compared to normal skin melanocytes. PRAME immunohistochemistry has proven effective in distinguishing melanocytic nevi from melanoma, but it is unclear if it may be used to distinguish melanoma in situ from other benign pigmented lesions. In particular, differentiating from melanocytic hyperplasia in sun-damaged skin is sometimes clinically and histopathologically challenging. We hypothesized that PRAME staining of solar lentigo, sun-damaged skin, and melanoma in situ would aid in setting a threshold of positivity that could be useful in evaluating such conditions.

METHODS

We collected and stained typical examples of solar lentigo, melanoma in situ, and non-lesional sun-damaged skin by PRAME immunohistochemistry to assess a potential cutoff of PRAME positivity.

RESULTS

Solar lentigo and non-lesional sun-damaged skin had 10 or fewer PRAME-positive cells per millimeter (mean 1.2), on the other hand melanoma in situ had at least 16 (mean 75.1).

CONCLUSIONS

PRAME immunostaining appears sensitive and specific in the current series. This could be clinically useful for distinguishing melanoma in situ from benign melanocytic hyperplasia in sun-damaged skin. However, further studies are required to determine if 10 cells per millimeter is an acceptable threshold of positivity.

Financial Hardship by Age at Diagnosis Including in Young Adulthood among African American Cancer Survivors

BACKGROUND

Financial hardship is most common among cancer survivors with the fewest financial resources at diagnosis; however, little is known about the financial outcomes of young adult (YA) survivors (ages 20-39 at diagnosis), despite their having fewer financial reserves than older adults.

METHODS

We utilized data from 3,888 participants in the population-based Detroit Research on Cancer Survivors cohort. Participants self-reported several forms of material and behavioral financial hardship (MFH and BFH, respectively). Psychological financial hardship (PFH) was measured using the Comprehensive Score for financial Toxicity (COST) score. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for financial hardship by age at diagnosis controlling for demographic, socioeconomic, and cancer-related factors.

RESULTS

MFH prevalence was inversely associated with age such that 72% of YA survivors reported MFH, 62% ages 40 to 54, 49% ages 55 to 64, and 33% ages 65 to 79 (PRadjusted YA vs. 65+: 1.75; 95% CI, 1.49-2.04; Ptrend < 0.001). BFH was also more common among YA survivors (26%) than those ages 65 to 79 (20%; PRadjusted: 1.50; 95% CI, 1.08-2.08; Ptrend = 0.019). Age was positively associated with financial wellbeing. COST scores ranged from 20.7 (95% CI, 19.0-22.4) among YA survivors to 27.2 (95% CI, 26.1-28.2) among adults 65 to 79 years old (Ptrend < 0.001).

CONCLUSIONS

In this population of African American cancer survivors, MFH and BFH were more common, and PFH was more severe, in YA survivors compared with those diagnosed as older adults.

IMPACT

Young adulthood at diagnosis should be considered a risk factor for cancer-related financial hardship and addressed in work designed to reduce the adverse financial impacts of cancer.

Adverse Effects of Total Body Irradiation: A Two-Decade, Single Institution Analysis

Purpose

Several adverse effects have been reported in the literature associated with total body irradiation (TBI). Reports of the adverse effects of TBI have been primarily drawn from single-institution retrospective analyses. We report, to our knowledge, one of the largest cohorts of patients treated with TBI using multiple preparative chemotherapy and radiation regimens.

Methods and Materials

A retrospective chart review was performed for all 705 patients treated with TBI at our institution from 1995 to 2017. Based on availability of TBI records, 622 patients (88%) had sufficient evaluable documentation for analysis. Patients received 1 of 4 conditioning regimens: busulfan-fludarabine, 2 Gy (BUFLU); fludarabine-melphalan, 2 Gy (FLUMEL); cyclophosphamide, 12 Gy fractionated (CY); or etoposide, 12 Gy fractionated (VP16). Individual patients were evaluated for 13 specific recognized adverse effects based on the Common Terminology Criteria for Adverse Events, version 5.0.

Results

Mucositis (grade 3) was the most common serious adverse effect and occurred most frequently in the group receiving the VP16 12 Gy regimen (40% vs less than 14% in each of the other groups). Serious febrile neutropenia (grade 3-5) was less frequent (24%) among patients receiving CY than among those receiving the other conditioning regimens (more than 38% in each of the other groups). The incidence of serious lung infection was less common (5%) in patients receiving CY than in those receiving VP16 (18%). There was a higher frequency of grade 3-5 diarrhea among those receiving FLUMEL (5%) and VP16 (4%) than in the other groups (<3%) (P = .034). Otherwise, there were no detectable differences in serious toxicity by regimen for the 13 adverse effects reviewed. Only 2 secondary malignancies were reported, and both were in the BUFLU group. Cataract formation occurred in approximately 16% of patients overall, and the rates were similar across regimens. Median time to cataract formation was 1 to 4 years across regimens, with cataracts occurring earlier in the 2-Gy regimens. The overall rate of grade ≥3 pneumonitis was approximately 2% across the entire cohort.

Conclusions

Our nearly 20-year TBI experience showed relatively low rates of radiation-related toxicities. However, cataracts were common with a relatively short onset time.

[Spontaneous course of traumatic tympanic membrane perforations]

BACKGROUND

Traumatic eardrum perforation is a common presentation in otorhinolaryngologic practices and emergency clinics. A consistent management strategy (active intervention vs. watchful waiting) is, however, still lacking.

OBJECTIVE

In the following study, the outcome of watchful waiting is analyzed and presented.

MATERIALS AND METHODS

A collective of 272 patients presenting at two different specialist ENT practices within days of traumatic tympanic membrane perforation from June 2002 to March 2019 were analyzed. Treatment was non-surgical, with prospective monitoring. Whereas antibiotics were not given at all in one practice, they were given only upon signs of infection in the other practice. The outcome was evaluated retrospectively on the basis of patient files.

RESULTS

The collective consisted of 185 males and 87 females. Mean age was 30 years (range: 7 months to 82 years). The perforations were most commonly located in the upper anterior and lower posterior quadrants. According to Griffin grading, the size was grade I in 97%. The three most common causes were impact to the ear, barotrauma, and foreign bodies. Under a watchful waiting regimen, 95% of the patients presenting for follow-up checks showed complete closure.

CONCLUSION

Watchful waiting can be assessed as appropriate in traumatic eardrum perforation, provided otorhinolaryngologic follow-up is ensured. An exception is blast injury, which is now much less common in Central Europe, as this is associated with a risk of secondary cholesteatomas. In these rare cases, active treatment with surgical exploration of the middle ear including relining the perforation is indicated.

Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors

The use of G-CSF after myelotoxic chemotherapy accelerates neutrophil recovery reducing the risk of febrile neutropenia. Current guidelines recommend initiating G-CSF 24 hours after myelotoxic chemotherapy. However, the optimal timing of post-chemotherapy G-CSF administration has not been elucidated. Our previous work in murine models demonstrated that the reappearance of myeloid progenitors does not occur in bone marrow until 3-4 days after completion of chemotherapy suggesting that delayed G-CSF administration may be equally efficacious compared to current practice. We conducted a prospective, randomized, crossover study to compare the absolute neutrophil count (ANC) recovery after chemotherapy and a delayed G-CSF administration to a standard G-CSF administration schedule with early G-CSF start. A total of 21 children with solid tumors who received 2 identical cycles of myelotoxic chemotherapy were randomized to start receiving G-CSF either 24 hours after completion of chemotherapy or on the day that their ANC dropped below 1,000/mm³. There was no significant difference in the time to neutrophil recovery (ANC > 1,000/mm³ post nadir) between the two G-CSF administration schedules: 16.0 ± 0.5 days in the standard group compared to 16.7 ± 0.4 days in the delayed group (p = 0.36). The total number of G-CSF doses given, however, was significantly less in the delayed group: 6.7 ± 0.6 compared to 10.5 ± 0.6 doses in the standard group (p < 0.0001). Our data show that a delayed administration of post chemotherapy G-CSF resulted in a significant reduction in the number of G-CSF injections without compromising the G-CSF effects on neutrophil recovery.

The impact of high intensity interval training on functional performance, body composition and quality of life in a diverse group of cancer survivors

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Background: Given the well-documented benefits of regular exercise to cancer survivors, in 2012, an expert panel assembled by the American Cancer Society recommended that patients engage in at least 150 minutes per week of moderate-to-vigorous physical activity. However, few patients meet this goal. We have also observed racial differences in reported participation in regular exercise among cancer survivors living in Metropolitan Detroit, Michigan. Methods: The CAPABLE study is a 12- week pilot exercise intervention that introduces cancer survivors to the sport of CrossFit. We evaluated the impact of this unique, high-intensity interval training method on functional performance, cardiovascular endurance, body composition and health-related quality of life (HRQOL) as measured by the Functional Assessment of Cancer Therapy (FACT) instrument. All measures were summarized at baseline and program exit. Paired signed rank tests were used to assess change in each of these measures over time. Results: Of the 48 participants enrolled in the pilot, 37 (77%) were considered adherent to the program (attending at least 75% of sessions over the 12-week period). The mean age of participants was 58.5 years, 73% identified as African American and the majority of participants were breast cancer survivors (N = 20). The mean body mass index (BMI) at baseline was 32.8 kg/m2 decreasing to a mean of 31.7 kg/m2 at exit (BMI change -1.1, p < 0.001). Similar changes were observed in % body fat measured by bioelectrical impedance. There were significant improvements in all measures of functional performance over 12-weeks (all p < 0.001). We observed significant and meaningful improvements in reported HRQOL measured by the FACT survey, overall (FACTG total change +9.5 (p < 0.001)) and in each one of the individual domains (physical, social, emotional, and functional well-being). Conclusions: We observed significant improvements in performance, body composition and quality of life among cancer survivors introduced to a high-intensity interval training program. Understanding and eliminating barriers to programs like these are critical to improving outcomes and reducing cancer health disparities. Clinical trial information: NCT03750981 .

Very long term follow-up of high dose chemotherapy followed by autologous stem cell transplantation in high risk locally advanced triple negative breast cancer

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Background: The role of High Dose Chemotherapy (HDC) with Autologous Stem Cell Transplantation (ASCT) in treatment of high risk locally advanced breast cancer remains unclear. This modality stopped being used for breast cancer treatment when trials in early 2000s reported Disease Free Survival (DFS) benefit but no Overall survival (OS) benefit. However, subgroup analyses of these studies reported OS benefit in young and Triple Negative Breast Cancer (TNBC). We report very long-term outcomes of high risk locally advanced TNBC treated with HDC-ASCT at our institution between 1995 and 2001. Methods: We reviewed our BMT database for women with stage IIB or III TNBC treated with HDC-ASCT. We excluded women with hormone positive, Her2/Neu positive/Unknown and metastatic disease prior to transplant per updated AJCC 7th edition. The majority of patients underwent surgery followed by adjuvant Anthracycline and Taxane based induction chemotherapy followed by HDC-ASCT for consolidation. The HDC regimen consisted of Carmustine 600 mg/m2, Cyclophosphamide 5.6gm/ m2 and Cisplatin 165mg/ m2 (STAMP 1 regimen). Four patients received induction regimen as neoadjuvant and HDC-ASCT as adjuvant treatment per the same protocol. All patients received loco-regional radiation after ASCT. Results: 29 patients had locally advanced TNBC treated with HDC-ASCT. Median age at diagnosis was 43 years (IQR 40-51). 28 had at least 4 positive lymph nodes. Median time from diagnosis to ASCT was 5 months. Median overall survival was 17 years (95% CI, 3-19 years), and median DFS was 14 years (95% CI, 1-19). There was no treatment related mortality (TRM) at 30- and 100-days post ASCT. 12 patients (41%) were alive at median of 16 years (95% CI, 12-19) post ASCT. Conclusions: This single institution study of locally advanced high risk TNBC patients who received HDC-ASCT as part of treatment demonstrates a high long term OS exceeded historical controls. This supports a potential role for HDC-ASCT in this cohort of high risk TNBC. Considering the low TRM associated with this approach, prospective evaluation of this strategy is warranted.

History of Inflammatory Bowel Disease and Self-Reported Oral Health: Women's Health Initiative Observational Study

Background and Objective: Both periodontal disease and inflammatory bowel disease (IBD), are chronic inflammatory conditions, which are mediated by a complex interplay among a dysbiotic microbiota, dysregulated host immune-inflammatory responses, and lifestyle factors. Despite substantial differences in physical and chemical environments, rather strong correlations have been detected between microbial compositions of the oral cavity and stool. In this study, we tested the hypothesis that oral health conditions are affected by the presence of IBD. Materials and Methods: We analyzed the data from 73,621 women who were enrolled in the Women's Health Initiative observational cohort study and completed a follow-up questionnaire that surveyed oral health status specifically at year 5. Among these, 880 reported IBD at the baseline, including 47% who were symptomatic cases and 27% who were on immunosuppressive treatment. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association of IBD and medication status for self-reported oral health outcomes, using logistic regression models, adjusted for selected covariates. Results: IBD was not associated with periodontal disease history itself in a multivariable model; however, poorer self-rated oral health was modestly associated with the presence of IBD (OR = 1.15, 95% CI: 1.01-1.30). Likewise, more frequent eating limitations due to teeth were associated with the presence of IBD history (OR = 1.22, 95% CI: 1.07-1.39). When IBD cases were limited to those who were symptomatic, the associations with these two self-rated oral health outcomes were more pronounced with ORs of 1.28 (95% CI: 1.07-1.54) and 1.36 (95% CI: 1.07-1.54), respectively. Immunosuppressive treatment had little effect on these risk estimates. Conclusions: Among this nation-wide cohort of women 50-79 years of age, history of IBD was associated with poorer perceived oral health status.

eHealth Activity among African American and White Cancer Survivors: A New Application of Theory

eHealth is a promising resource for cancer survivors and may contribute to reducing racial disparities in cancer survivorship. This research applies the Unified Theory of Acceptance and Use of Technology (UTAUT) to examine eHealth activity among African American (AfAm) and White cancer survivors. In a population-based sample of AfAm and White survivors (n = 300), a Poisson regression tested whether UTAUT constructs (facilitating conditions, social influence, perceived ease of use, perceived usefulness) and beliefs about security/trustworthiness of eHealth were associated with the number of eHealth activities respondents had used. To test whether the effects varied across racial groups, interactions between each of these five facets and survivor race were included in the model. The model adjusted for demographic characteristics, cancer history, and internet access and use. Across racial groups, facilitating conditions (IRR = 1.44, 95%CI [1.17, 1.77]) and perceived usefulness (IRR = 1.16, 95%CI [1.08, 1.24]) were associated with increased eHealth activity. A marginally significant interaction between race and perceived ease of use (IRR = 1.17, 95%CI [0.99, 1.39]) indicated this perception was associated with decreased eHealth activity for White but not AfAm survivors. A significant interaction between race and perceived security/trustworthiness (IRR = 1.16, 95%CI [1.02, 1.32]) indicated this perception was associated with increased eHealth activity for AfAm but not White survivors. Social influence was not associated with eHealth use for either group (IRR = 1.07, 95%CI [0.98, 1.16]). Interventions targeting attitudes about eHealth may encourage its adoption and use. Furthermore, eHealth tools intended for use among AfAm cancer survivors should ensure they are secure and emphasize trustworthiness to intended users.

Smartphone apps for cancer: A content analysis of the digital health marketplace

Objective

The purpose of this study was to examine the state of smartphone applications for cancer intended for the general public with a focus on interactive features, content sources, and application developer affiliations. The level of health provider involvement in screening or appraising application content was also assessed.

Methods

A total of 123 apps were identified for analysis from two major mobile application marketplaces (Apple iTunes = 40; Google Play = 83). Application characteristics were collected, analyzed, and reported. These included the mobile platform, cost, application developer affiliation, date of last update, purpose of application, content sources, and interactive features.

Results

In the study sample, 50% of the applications focused on general information for cancer (62/123). Next, this was followed by applications for breast cancer (15%, 19/123) and skin cancer (7%, 8/123). Only 10% of application descriptions (12/123) identified sources for application content. Interactive features included the ability to monitor symptoms, side effects, treatments, and chronic pain (20%, 25/123). Only 3% of the applications (4/123) stated content had been evaluated by health providers.

Conclusions

This study contributes an updated analysis of applications for cancer available in the digital health marketplace. The findings have implications for information quality and supportive resources for cancer care. More transparent information about content sources, organizational affiliations, and level of health provider oversight in screening application content is warranted. Recommendations for improving the quality of cancer applications are also offered.

A retrospective study evaluating the pretreatment tumor volume (PTV) in non-small cell lung cancer (NSCLC) as a predictor of response to program death-1 (PD-1) inhibitors

Introduction of hypothesis

Little information is available regarding the imaging characteristics that assist in differentiating responders from non-responders. We hypothesized that patients with higher pretreatment tumor volume (PTV) would have lower response rates and shorter overall survival (OS).

Methods

Data from patients who received at least one dose of program death-1 (PD-1) inhibitors before August 31, 2016 were captured from our institution’s pharmacy database. The primary objective was to determine the association of PTV with best response, evaluated utilizing RECIST v1.1 criteria. Secondary objectives were estimation of progression-free survival (PFS) and OS. PTV was measured using the Philips Intellispace Multi-Modality Tumor Tracking application.

Results

116 non-small cell lung cancer (NSCLC) patients were evaluated. 66% patients had adenocarcinoma, 28% had squamous cell carcinoma and 5% had poorly differentiated NSCLC. Median PTV was 53.7 cm³ (95% CI: 13.3–107.9). Only one individual had no metastases and the remainder had M1 disease; 38% M1a, 10% M1b, 51% M1c. Most (79%) were previously treated. There were no complete responses; among those followed for at least 6 weeks, 26% had a partial response, 39% stable disease and 34% PD; 4% had no recorded response. There were no strong associations of PTV with any of the demographic or clinical characteristics. There was no association between PTV and OS (HR 1.2, P=0.26) or PFS (HR 1.1, P=0.47). Liver metastasis was associated with shorter survival (HR=2.8, P=0.05).

Conclusion

PTV in NSCLC did not prove to be a predictor of response to PD-1 inhibitors but having liver metastasis was associated with significantly shorter survival.

Serum folate receptor α (sFR) in ovarian cancer diagnosis and surveillance

Novelty and Impact Statement: Our findings suggest that soluble folate receptor (sFR) could be used in both the initial diagnosis and surveillance of patients with ovarian cancer. Our cohort constitutes one of the largest comparison groups for sFR analyzed so far. We have defined the background level of sFR using healthy volunteers. This is also the first study to prospectively follow patients in the surveillance setting to concurrently identify differential changes in tumor markers CA-125 and sFR.

Serum folate receptor α (sFR) in ovarian cancer diagnosis and surveillance

Novelty and Impact Statement: Our findings suggest that soluble folate receptor (sFR) could be used in both the initial diagnosis and surveillance of patients with ovarian cancer. Our cohort constitutes one of the largest comparison groups for sFR analyzed so far. We have defined the background level of sFR using healthy volunteers. This is also the first study to prospectively follow patients in the surveillance setting to concurrently identify differential changes in tumor markers CA-125 and sFR.

Abstract GS4-07: Race, ethnicity and clinical outcomes in hormone receptor-positive, HER2-negative, node-negative breast cancer: results from the TAILORx trial

Background: Black race is associated with worse outcomes in localized hormone receptor (HR)-positive breast cancer in population-based and in clinical trial cohorts, whether using self-identified race (Albain et al. JNCI 2009 [PMID: 19584328; Sparano et al. JNCI 2012 [PMID: 22250182) or genetically-identified race (Schneider et al. J Precision Oncol 2017 [PMID: 29333527]). This disparity persists after adjustment for treatment delivery parameters (Hershman et al. JCO 2009 [PMID:19307504]). We evaluated clinicopathologic characteristics, treatment delivered and clinical outcomes in the Trial Assigning Individualized Options for Treatment (TAILORx) by race and ethnicity (Sparano et al. NEJM 2018 [PMID: 29860917]).

Methods: The analysis included 9719 evaluable TAILORx participants. The association between clinical outcomes and race (white, black, Asian, other/unknown) and ethnicity (Hispanic vs. non-Hispanic) was examined, including invasive disease-free survival (iDFS), distant relapse-free interval (DRFI), relapse-free interval (RFI), and overall survival (OS). Proportional hazards models were fit including age (5 categories), tumor size (&gt;2 cm vs. &lt;=2 cm), histologic grade (high vs. medium vs. low vs. unknown), continuous recurrence score (RS), race, and ethnicity in the overall population and randomized treatment arms in the RS 11-25 cohort.

Results: The study population included 8189 (84%) whites, 693 (7%) blacks, 405 (4%) Asians, and 432 (4%) with other/unknown race. Regarding ethnicity, 7635 (79%) were non-Hispanic, 889 (9%) Hispanic, and 1195 (12%) unknown. There was no significant difference in RS distribution (p=0.22) in blacks compared with whites, or in median (17 vs. 17) or mean RS (19.1 vs. 18.2). There was likewise no difference in Hispanic vs. non-Hispanic ethnicity for RS distribution (p=0.72) or median (17 vs. 17) or mean RS (18.5 vs. 18.0). Black race (39% vs. 30%) and Hispanic ethnicity (39% vs. 30%) were both associated with younger age (&lt;/=50 years) at diagnosis. The use and type of adjuvant chemotherapy and endocrine therapy, and duration of endocrine therapy, were similar in black (vs. white) and Hispanic (vs. non-Hispanic) populations. In proportional hazards models, black race (compared with white race) was associated with worse clinical outcomes in the entire population and in those with a RS 11-25 (see table). Hispanic ethnicity was generally associated with better outcomes (compared with non-Hispanic ethnicity). For the cohort with a RS of 11-25, there was no evidence for chemotherapy benefit for any racial or ethnic group.

Race (black vs.white) and clinical outcomes in proportional hazards modelsClinical endpointEntire Population (N=693 black) Hazard ratio for eventRS 11-25 (N=471 black) Hazard ratio for eveniDFS1.33 (p=0.005)1.49 (p=0.001)DRFI1.21 (p=0.28)1.60 (p=0.02)RFI1.39 (p=0.02)1.80 (p&lt;0.001)OS1.52 (p=0.005)1.67 (p=0.003

Conclusions: In patients eligible and selected for participation in TAILORx, black women had worse clinical outcomes despite similar 21-gene assay RS results and comparable systemic therapy. This adds to an emerging body of evidence suggesting a biologic basis or other factors contributing to racial disparities in HR-positive breast cancer that requires further evaluation.

Citation Format: Albain K, Gray RJ, Sparano JA, Makower DF, Pritchard KI, Hayes DF, Geyer, Jr. CE, Dees EC, Goetz MP, Olson, Jr. JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Ravdin PM, Keane MM, Gomez HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Berenberg JL, Abrams J, Sledge, Jr. GW. Race, ethnicity and clinical outcomes in hormone receptor-positive, HER2-negative, node-negative breast cancer: results from the TAILORx 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 GS4-07.

Serum folate receptor α (sFR) in ovarian cancer diagnosis and surveillance

Novelty and Impact Statement: Our findings suggest that soluble folate receptor (sFR) could be used in both the initial diagnosis and surveillance of patients with ovarian cancer. Our cohort constitutes one of the largest comparison groups for sFR analyzed so far. We have defined the background level of sFR using healthy volunteers. This is also the first study to prospectively follow patients in the surveillance setting to concurrently identify differential changes in tumor markers CA‐125 and sFR.

The Detroit Research on Cancer Survivors (ROCS) Pilot Study: A Focus on Outcomes after Cancer in a Racially Diverse Patient Population

BACKGROUND

African Americans are often diagnosed with advanced stage cancer and experience higher mortality compared with whites in the United States. Contributing factors, like differences in access to medical care and the prevalence of comorbidities, do not entirely explain racial differences in outcomes.

METHODS

The Detroit Research on Cancer Survivors (ROCS) pilot study was conducted to investigate factors related to short- and long-term outcomes among patients with cancer. Participants completed web-based surveys, and mailed saliva specimens were collected for future genetic studies.

RESULTS

We recruited 1,000 participants with an overall response rate of 68%. Thirty-one percent completed the survey without any interviewer support and the remaining participated in an interviewer-administered survey. Seventy-four percent provided a saliva specimen and 64% consented for tumor tissue retrieval. African American survivors required more interviewer support (P < 0.001); however, their response rate (69.6%) was higher than non-Hispanic whites (65.4%). African Americans reported poorer overall cancer-related quality of life compared with non-Hispanic whites, measured by FACT-G score (P < 0.001), however, this relationship was reversed after controlling for socioeconomic factors, marital status, and the presence of comorbidities.

CONCLUSIONS

In this pilot study, we demonstrated that a web-based survey supplemented with telephone interviews and mailed saliva kits are cost-effective methods to collect patient-reported data and DNA for large studies of cancer survivors with a high proportion of minority patients. The preliminary data collected reinforces differences by race in factors affecting cancer outcomes. Our efforts continue as we expand this unique cohort to include more than 5,000 African American cancer survivors.

IMPACT

Formal investigation of factors influencing adverse outcomes among African American cancer survivors will be critical in closing the racial gap in morbidity and mortality.

Impacts of Regulations on Air Quality and Emergency Department Visits in the Atlanta Metropolitan Area, 1999-2013

INTRODUCTION

The United States and Western Europe have seen great improvements in air quality, presumably in response to various regulations curtailing emissions from the broad range of sources that have contributed to local, regional, and global pollution. Such regulations, and the ensuing controls, however, have not come without costs, which are estimated at tens of billions of dollars per year. These costs motivate accountability-related questions such as, to what extent do regulations lead to emissions changes? More important, to what degree have the regulations provided the expected human health benefits?

Here, the impacts of specific regulations on both electricity generating unit (EGU) and on-road mobile sources are examined through the classical accountability process laid out in the 2003 Health Effects Institute report linking regulations to emissions to air quality to health effects, with a focus on the 1999-2013 period. This analysis centers on regulatory actions in the southeastern United States and their effects on health outcomes in the 5-county Atlanta metropolitan area. The regulations examined are largely driven by the 1990 Clean Air Act Amendments (C). This work investigates regulatory actions and controls promulgated on EGUs: the Acid Rain Program (ARP), the NOx Budget Trading Program (NBP), and the Clean Air Interstate Rule (CAIR) - and mobile sources: Tier 2 Gasoline Vehicle Standards and the 2007 Heavy Duty Diesel Rule.

METHODS

Each step in the classic accountability process was addressed using one or more methods. Linking regulations to emissions was accomplished by identifying major federal regulations and the associated state regulations, along with analysis of individual facility emissions and control technologies and emissions modeling (e.g., using the U.S. Environmental Protection Agency's [U.S. EPA's] MOtor Vehicle Emissions Simulator [MOVES] mobile-source model). Regulators, including those from state environmental and transportation agencies, along with the public service commissions, play an important role in implementing federal rules and were involved along with other regional stakeholders in the study. We used trend analysis, air quality modeling, satellite data, and a ratio-of-ratios technique to investigate a critical current issue, a potential large bias in mobile-source oxides of nitrogen (NOx) emissions estimates.

The second link, emissions-air quality relationships, was addressed using both empirical analyses as well as chemical transport modeling employing the Community Multiscale Air Quality (CMAQ) model. Kolmogorov-Zurbenko filtering accounting for day of the year was used to separate the air quality signal into long-term, seasonal, weekday-holiday, and short-term meteorological signals. Regression modeling was then used to link emissions and meteorology to ambient concentrations for each of the species examined (ozone [O3], particulate matter ≤ 2.5 μm in aerodynamic diameter [PM2.5], nitrogen dioxide [NO2], sulfur dioxide [SO2], carbon monoxide [CO], sulfate [SO4-2], nitrate [NO3-], ammonium [NH4+], organic carbon [OC], and elemental carbon [EC]). CMAQ modeling was likewise used to link emissions changes to air quality changes, as well as to further establish the relative roles of meteorology versus emissions change impacts on air quality trends. CMAQ and empirical modeling were used to investigate aerosol acidity trends, employing the ISORROPIA II thermodynamic equilibrium model to calculate pH based on aerosol composition. The relationships between emissions and meteorology were then used to construct estimated counterfactual air quality time series of daily pollutant concentrations that would have occurred in the absence of the regulations. Uncertainties in counterfactual air quality were captured by the construction of 5,000 pollutant time series using a Monte Carlo sampling technique, accounting for uncertainties in emissions and model parameters.

Health impacts of the regulatory actions were assessed using data on cardiorespiratory emergency department (ED) visits, using patient-level data in the Atlanta area for the 1999-2013 period. Four outcome groups were chosen based on previous studies identifying associations with ambient air pollution: a combined respiratory disease (RD) category; the subgroup of RD presenting with asthma; a combined cardiovascular disease (CVD) category; and the subgroup of CVD presenting with congestive heart failure (CHF).

Models were fit to estimate the joint effects of multiple pollutants on ED visits in a time-series framework, using Poisson generalized linear models accounting for overdispersion, with a priori model formulations for temporal and meteorological covariates and lag structures. Several parameterizations were considered for the joint-effects models, including different sets of pollutants and models with nonlinear pollutant terms and first-order interactions among pollutants. Use of different periods for parameter estimates was assessed, as associations between pollutant levels and ED visits varied over the study period. A 7-pollutant, nonlinear model with pollutant interaction terms was chosen as the baseline model and fitted using pollutant and outcome data from 1999-2005 before regulations might have substantially changed the toxicity of pollutant mixtures. In separate analyses, these models were fitted using pollutant and outcome data from the entire 1999-2013 study period. Daily counterfactual time series of pollutant concentrations were then input into the health models, and the differences between the observed and counterfactual concentrations were used to estimate the impacts of the regulations on daily counts of ED visits. To account for the uncertainty in both the estimation of the counterfactual time series of ambient pollutant levels and the estimation of the health model parameters, we simulated 5,000 sets of parameter estimates using a multivariate normal distribution based on the observed variance-covariance matrix, allowing for uncertainty at each step of the chain of accountability. Sensitivity tests were conducted to assess the robustness of the results.

RESULTS

EGU NOx and SO2 emissions in the Southeast decreased by 82% and 83%, respectively, between 1999 and 2013, while mobile-source emissions controls led to estimated decreases in Atlanta-area pollutant emissions of between 61% and 93%, depending on pollutant. While EGU emissions were measured, mobile-source emissions were modeled. Our results are supportive of a potential high bias in mobile-source NOx and CO emissions estimates. Air quality benefits from regulatory actions have increased as programs have been fully implemented and have had varying impacts over different seasons. In a scenario that accounted for all emissions reductions across the period, observed Atlanta central monitoring site maximum daily 8-hour (MDA8h) O3 was estimated to have been reduced by controls in the summertime and increased in the wintertime, with a change in mean annual MDA8h O3 from 39.7 ppb (counterfactual) to 38.4 ppb (observed). PM2.5 reductions were observed year-round, with average 2013 values at 8.9 μg/m3 (observed) versus 19.1 μg/m3 (counterfactual). Empirical and CMAQ analyses found that long-term meteorological trends across the Southeast over the period examined played little role in the distribution of species concentrations, while emissions changes explained the decreases observed. Aerosol pH, which plays a key role in aerosol formation and dynamics and may have health implications, was typically very low (on the order of 1-2, but sometimes much lower), with little trend over time despite the stringent SO2 controls and SO42- reductions.

Using health models fit from 1999-2005, emissions reductions from all selected pollution-control policies led to an estimated 55,794 cardiorespiratory disease ED visits prevented (i.e., fewer observed ED visits than would have been expected under counterfactual scenarios) - 52,717 RD visits, of which 38,038 were for asthma, and 3,057 CVD visits, of which 2,104 were for CHF - among the residents of the 5-county area over the 1999-2013 period, an area with approximately 3.5 million people in 2013. During the final two years of the study (2012-2013), when pollution-control policies were most fully implemented and the associated benefits realized, these policies were estimated to prevent 5.9% of the RD ED visits that would have occurred in the absence of the policies (95% interval estimate: -0.4% to 12.3%); 16.5% of the asthma ED visits (95% interval estimate: 7.5% to 25.1%); 2.3% of the CVD ED visits (95% interval estimate: -1.8% to 6.2%); and -.6% of the CHF ED visits (95% interval estimate: 26.3% to 10.4%). Estimates of ED visits prevented were generally lower when using health models fit for the entire 1999-2013 study period.

Sensitivity analyses were conducted to show the impact of the choice of parameterization of the health models and to assess alternative definitions of the study area. When impacts were assessed for separate policy interventions, policies affecting emissions from EGUs, especially the ARP and the NBP, appeared to have had the greatest effect on prevention of RD and asthma ED visits.

CONCLUSIONS

This study demonstrates the effectiveness of regulations on improving air quality and health in the southeastern United States. It also demonstrates the complexities of accountability assessments as uncertainties are introduced in each step of the classic accountability process. While accounting for uncertainties in emissions, air quality-emissions relationships, and health models does lead to relatively large uncertainties in the estimated outcomes due to specific regulations, overall the benefits of regulations have been substantial.

Multianalyte Tests for the Early Detection of Cancer: Speedbumps and Barriers

It has become very clear that a single molecular event is inadequate to accurately predict the biology (or pathophysiology) of cancer. Furthermore, using any single molecular event as a biomarker for the early detection of malignancy may not comprehensively identify the majority of individuals with that disease. Therefore, the fact that technologies have arisen that can simultaneously detect several, possibly hundreds, of biomarkers has propelled the field towards the development of multianalyte-based in vitro diagnostic early detection tests for cancer using body fluids such as serum, plasma, sputum, saliva, or urine. These multianalyte tests may be based on the detection of serum autoantibodies to tumor antigens, the presence of cancer-related proteins in serum, or the presence of tumor-specific genomic changes that appear in plasma as free DNA. The implementation of non-invasive diagnostic approaches to detect early stage cancer may provide the physician with evidence of cancer, but the question arises as to how the information will affect the pathway of clinical intervention. The confirmation of a positive result from an in vitro diagnostic cancer test may involve relatively invasive procedures to establish a true cancer diagnosis. If in vitro diagnostic tests are proven to be both specific, i.e. rarely produce false positive results due to unrelated conditions, and sufficiently sensitive, i.e. rarely produce false negative results, then such screening tests offer the potential for early detection and personalized therapeutics using multiple disease-related targets with convenient and non-invasive means. Here we discuss the technical and regulatory barriers inherent in development of clinical multianalyte biomarker assays.

Toxicities associated with checkpoint inhibitor immunotherapy: The Karmanos Cancer Center experience

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Background: PD-1 inhibitors work by re-instating the natural anti-cancer immune-mediated cytotoxicity. Although this new class of therapy offers hope for many advanced stage cancer patients (pts), data on pts who are more likely to experience adverse events (AE) are not available. Methods: Data from pts who received at least one dose of PD-1 inhibitors before August 31, 2016, were captured from our institution’s pharmacy database. AE of anemia, neutropenia, thrombocytopenia, acute kidney injury, hypothyroidism, transaminitis, pneumonitis, colitis and fatigue were recorded and graded based on CTCAEv4. Baseline pt characteristics were statistically compared between subjects who received PD-1 inhibitors on a clinical trial vs as part of standard of care (on vs. off-study) by Fisher’s exact test for categorical variables and Kruskal-Wallis test for continuous variables. Univariable and multivariable logistic regression models were fit to assess associations between toxicities (Grade0-1 vs. Grade2+) and predictors (age, agent, primary tumor, and trial status). Results: 231 pts received at least one dose of PD-1 inhibitors prior to data cut-off. Median age was 65 (24-92) off trial (n = 125) and 59. 5 (25-79) on trial (n = 106). There were 117 (51%) non-small cell lung cancer (NSCLC), 41 (18%) renal cell carcinoma (RCC) and 73 (32%) others. 24 (10%) melanoma, 18 (8%) Hodgkin’s lymphoma (HL), 9 (4%) head and neck squamous cell carcinoma (HNSCC), 8 (4%) small cell lung cancer (SCLC) were included in others. 129 (56%) had nivolumab alone, 50 (22%) had pembrolizumab alone and the rest 52 (23%) received combination treatment. Pts participating in a clinical trial had higher odds to experience grade 2 or more pneumonitis than those not on a trial (unadjusted p = 0.038). On trial pts had lower odds to experience grade 2 or more fatigue than those receiving the agent as standard of care (unadjusted p = 0.026) which remained significant after adjusting age, agent (single agent vs combination) and primary tumor (adjusted p = 0.004). Conclusions: In our observation, pneumonitis was seen more on clinical trials whereas fatigue was seen less.

Long term follow up of patients with locally advanced triple negative breast cancer treated with adjuvant high dose chemotherapy and autologous stem cell transplantation: A single center experience

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Background: Adjuvant high dose chemotherapy (HDC) with Autologous Hematopoietic Stem Cell Transplantation (AuSCT) as part treatment of high risk locally advanced breast cancer has remained controversial. Multiple trials reported disease free survival (DFS) without Overall survival (OS) resulting in its abandonment in early 2000s. However, post hoc analysis of these trials consistently reported DFS and OS benefit in young and triple negative breast cancer (TNBC) subgroups. This has not been re-evaluated till date. Recent European registry reports coupled with improved transplant related mortality (TRM) and still poor out-come of standard of care in TNBC subgroup has generated renewed interest. We report long term out-come of locally advanced high risk TNBC treated with HDC and AuSCT treated in Karmanos Cancer Institute from 1995 to 2001 Methods: Majority of the patients were treated with Adriamycin and Taxane based induction chemotherapy. Patients without evidence of metastatic disease proceeded to HDC and AuSCT using Carmustine 600mg/sqm Cyclophosphamide 5.6gm/sqm and Cisplatin 165mg/sqm (STAMP 1 regimen). This is followed with loco- regional radiation per protocol. Results: 72 hormone negative patients with Lymph Node(LN) > 4 or inflammatory breast cancers were selected from 576 treated for advanced or metastatic breast cancer. 33 patients were TNB with HER2 status of 39 patients unknown. Median time from diagnosis to stem cell transplantation was 6 months. Median age at diagnosis was 47yrs. Mean LN involvement was 9 with 90% having (4-20) LN positivity. With median follow up of 16 years,10yrs DFS and OS were both 62.5%. Median follow up for DFS and OS was not reached.TRM was 9% mostly from pulmonary toxicity. Conclusions: This study of locally advanced high risk TNBC treated with adjuvant HDC and AuSCT have high 10yr OS of 62.5% compared to current standard of care. With the current improvement in TRM, reevaluation of this strategy through clinical trials in this subgroup whose outcome remain poor is reasonable.

Definitive chemoradiotherapy with carboplatin for squamous cell carcinoma of the head and neck

OBJECTIVE

Definitive concurrent chemoradiotherapy (CRT) is considered the standard of care for organ preservation and is the only potentially curative therapy for surgically unresectable patients with stage III to IVb locally advanced squamous cell carcinoma of the head and neck. In patients with high risks for adverse events utilizing cisplatin, carboplatin has been empirically substituted. The objective of this study was to estimate the locoregional control rate, progression-free survival, overall survival, and adverse events in locally advanced squamous cell carcinoma of the head and neck patients treated with CRT utilizing carboplatin.

STUDY DESIGN

A retrospective single-arm analysis.

METHODS

Data on consecutive patients who fit the eligibility criteria were collected. Eligible patients were treated with 70 Gy of radiation therapy and at least two cycles of carboplatin (area of curve [AUC] of 5 between January 2007 to December 2013.

RESULTS

Fifty-four patients were identified. Overall locoregional control rate was 50% (95% confidence interval [CI] 37%-63%). Median progression-free and overall survival were 21 (CI 11-33) and 40 (CI 33-NA) months, respectively. One-, 3-, and 5-year overall survival were 81% (CI 67%-89%), 59% (CI 41%-73%), and 42% (CI 22%-61%), respectively. Stage III/IVa patients (n = 45) had a median survival of 62 (CI 37-NA months) and 3 years of 71% (CI 53%-84%), whereas stage IVb (n = 9) had a median survival of 31 (CI 4-NA) months and none survived to 3 years.

CONCLUSION

Definitive CRT with carboplatin for locally advanced squamous cell carcinoma of the head and neck was well tolerated and demonstrated comparable results to CRT with cisplatin.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2260-2264, 2017.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

A Bayesian nonlinear mixed-effects disease progression model

A nonlinear mixed-effects approach is developed for disease progression models that incorporate variation in age in a Bayesian framework. We further generalize the probability model for sensitivity to depend on age at diagnosis, time spent in the preclinical state and sojourn time. The developed models are then applied to the Johns Hopkins Lung Project data and the Health Insurance Plan for Greater New York data using Bayesian Markov chain Monte Carlo and are compared with the estimation method that does not consider random-effects from age. Using the developed models, we obtain not only age-specific individual-level distributions, but also population-level distributions of sensitivity, sojourn time and transition probability.

Electric Blanket Use and Risk of Thyroid Cancer in the Women's Health Initiative Observational Cohort

Thyroid cancer disproportionally affects more women than men. The aim of this study was to assess whether exposure to extremely low frequency electric magnetic fields from electric blankets (EBs) was associated with the development of thyroid cancer. Data were analyzed from 89,527 women who participated in the Women's Health Initiative Observational Study and who responded to questions concerning prior use of EBs. During a mean follow-up of 12.2 years, 190 incident cases of thyroid cancer were identified. We estimated the hazard ratio (HR) and 95 percent confidence interval (CI) of incident thyroid cancer associated with EB use by Cox's proportional hazard model, adjusted for selected covariates. A majority, 57 percent, of the women in the cohort reported the use of EBs while sleeping and/or for warming the bed before sleep. No association was found between use of EBs and subsequent risk of thyroid cancer (HR = 0.98, 95 percent CI 0.72-1.32). Duration of EB use measured in years, months, or hours had no effect on risk. These results did not change when the cases were limited to papillary thyroid cancer, the most frequently occurring histologic type. The results of this study do not support possible health hazards of EBs in regards to thyroid cancer risk.

Abstract P2-08-02: Autoimmunity to centrosomal and proteasome proteins in breast cancer. A link to chromosome instability?

BACKGROUND. Perturbation of centrosomal or centrosome-associated proteins has been observed in nearly all human solid tumors and has been implicated in the origin of chromosomal instability. Ubiquitin-proteasome degradation is highly dependent on the organizing capabilities of the centrosomes. Here we report that autoantibodies in breast cancer [BC] sera target centrosomal proteins as well as important proteins involved in proteasome protein degradation.

METHODS. We immunoscreened a T7 cDNA library of BC proteins and the association of the cloned autoantigens with BC was studied by autoantigen microarray analysis. We used immunohistochemistry [IHC] to investigate the expression of the centrosome and centrosome-associated autoantigens identified.

RESULTS. Immunoscreening with BC sera led to the identification of autoantibodies recognizing epitopes developing in a family of proteins located on the centrosomes such as NIMA-related kinase 7, dynein heavy chain domain 3, peri-centriolar material-1, isomorph CRA, and stathmin-1, the ubiquitin-conjugating enzyme E2, the proteasome 26S subunit and the SUMO/sentrin peptidase. Antibody reactivity to these proteins which are associated with centrosome assembly, microtubule function and protein degradation were highly associated with the diagnosis of BC. IHC staining of paraffin-embedded BC sections with specific antibodies showed that aurora and stathmin-1 and other centrosome antigens are expressed in BC.

CONCLUSIONS. The discovery of autoantibodies targeting important centrosome and proteasome proteins associated with BC suggests that this immune reactivity could be related to autoimmunity developing in BC. Our findings indicate that these autoantibodies might be biomarkers of early BC and suggest the possibility of a link with chromosomal instability in BC.

Citation Format: Marie-Claire Maroun, Ofelia Olivero, Judith Abrams, Wei Chen, Azadeh Stark, Carol Peebles, Larry Tait, Dhanajay Chitale, Félix Fernández Madrid. Autoimmunity to centrosomal and proteasome proteins in breast cancer. A link to chromosome instability? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-08-02.

Evaluating the effects of lenalidomide induction therapy on peripheral stem cells collection in patients undergoing autologous stem cell transplant for multiple myeloma

INTRODUCTION

Lenalidomide (LEN) is a relatively new and very effective therapy for multiple myeloma (MM). Prior LEN therapy is associated with an increased risk of peripheral blood stem cell collection (PBSC) failure, particularly with filgrastim (G-CSF) alone. We performed a retrospective chart review of 319 consecutive MM patients who underwent apheresis to collect PBSCs for the first autologous stem cell transplant (ASCT).

RESULTS

The median number of PBSCs collected in the LEN (+) group was significantly less than the LEN (-) group (6.34 vs. 7.52 × 10(6) CD34(+) cells/kg; p = 0.0004). In addition, the median number of apheresis sessions required for adequate PBSCs collection were significantly more in the LEN (+) group as compared to LEN (-) group (2 vs. 1 sessions; p = 0.002). In the LEN (+) group, there was a negative correlation between PBSCs collected and prior number of cycles of LEN (p = 0.0001). Rate of PBSC collection failure was 9% in the LEN (+) group and 5% in the LEN (-) group (p = 0.16). Only six patients who failed PBSC collection with G-CSF were able to collect adequate PBSCs with G-CSF + plerixafor. LEN exposure had no effect on neutrophil or platelet recovery post-ASCT.

CONCLUSIONS

Up to four cycles of LEN exposure have minimal negative impact on PBSC collection. Despite prolong exposure of LEN, PBSC collection was adequate for two ASCTs in the majority of patients and post-ASCT engraftment was not longer than expected; however, clinical relevance (complication rate, quality of life, cost) of prolonged LEN exposure on both PBSC and ASCT, should be evaluated in prospective clinical trials.

Long-term follow up of patients proceeding to transplant using plerixafor mobilized stem cells and incidence of secondary myelodysplastic syndrome/AML

We report the long-term follow up of 49 patients (pts) enrolled on plerixafor compassionate use protocol. Thirty-seven pts (76%) had failed one previous mobilization attempt, while 12 (24%) had failed two or more previous attempts. Using the combination of plerixafor and granulocyte colony-stimulating factor, we collected2.5 × 10(6) CD34+cells/kg in 33 pts (67%). Forty-three of the 49 pts proceeded to an auto-SCT (ASCT). The median days to WBC and platelet engraftment were 11 (range, 9-13 days) and 16 (range, 11-77 days) days post ASCT, respectively. The median WBC count, Hb and platelet counts 1 year after ASCT were 4.7 × 10(9)/L, 12.2 g/dL and 109 × 10(9)/L, respectively. With median follow up of 42 months (range <1-54 months), 21 pts had evidence of disease progression. Five pts developed myelodysplastic syndrome (MDS)/AML at median of 29 months post ASCT. The cumulative incidence of MDS/AML at 42 months was 17% (95% confidence interval, 6 to 32%). Development of secondary MDS/AML in pts proceeding to ASCT after plerixafor mobilization needs to be studied further in a larger cohort.

Aprepitant for prevention of nausea and vomiting secondary to high-dose cyclophosphamide administered to patients undergoing autologous peripheral blood stem cells mobilization: a phase II trial

This is a phase II trial evaluating efficacy and safety of aprepitant (AP) in combination with 5-HT3 antagonist and adjusted dose dexamethasone in patients receiving high-dose cyclophosphamide (CY) and filgrastim for stem cell mobilization. We used Simon's optimal two-stage design constrained to fewer than 40 patients with 10% type I error and 85% statistical power. The first stage of the study required accrual of 18 response-evaluable patients. The primary endpoint was the control of vomiting without the use of any rescue anti-emetics at 24 h after the administration of high dose CY (4 g/m(2)). If emesis was controlled in ≥9 patients, an additional cohort of 17 patients would be enrolled. The null hypothesis would be rejected if there were ≥20 responses among 35 patients. Forty patients were enrolled, five of whom were not evaluable for response. Eighteen evaluable patients were enrolled in the first stage. Acute emesis was controlled in 10 patients; therefore, enrollment proceeded to stage 2. An additional 17 patients were enrolled; 20/35 response-evaluable patients (57%) did not develop acute vomiting or require rescue anti-emetics, thus achieving the goal of the study. A total of 22/35 response-evaluable patients (63%) met the secondary endpoint of delayed emesis control (days 2-5). Thirty-three out of 35 patients underwent successful stem cell mobilization. No ≥ grade 3 AP-related adverse events were noted. The AP regimen can effectively control acute and delayed emesis in the majority patients receiving high-dose CY.

HDM2 antagonist MI-219 (spiro-oxindole), but not Nutlin-3 (cis-imidazoline), regulates p53 through enhanced HDM2 autoubiquitination and degradation in human malignant B-cell lymphomas

Background

Lymphomas frequently retain wild-type (wt) p53 function but overexpress HDM2, thereby compromising p53 activity. Therefore, lymphoma is a suitable model for studying the therapeutic value of disrupting the HDM2-p53 interaction by small-molecule inhibitors (SMIs). HDM2 have been developed and are under various stages of preclinical and clinical investigation. Previously, we examined the anti-lymphoma activity of MI-319, the laboratory grade of a new class of HDM2 SMI, the spiro-oxindole, in follicular lymphoma. Since then, MI-219, the clinical grade has become readily available. This study further examines the preclinical effects and mechanisms of MI-219 in a panel of human lymphoma cell lines as well as a cohort of patient-derived B-lymphcytes for its potential clinical use.

Results

Preclinical assessment of MI-219 was evaluated by means of an in vitro and ex vivo approach and compared to Nutlin-3, the gold standard. Characterization of p53 activity and stability were assessed by quantitative PCR, Western blot, and immunoprecipitation. Biological outcome was measured using Trypan blue exclusion assay, Annexin V/PI, PARP and caspase-3 cleavage. Surprisingly, the overall biological effects of Nutlin-3 were more delayed (48 h) while MI-219 triggered an earlier response (12-24 h), predominantly in the form of apoptotic cell death. Using a cell free autoubiquitination assay, neither agent interfered with HDM2 E3 ligase function. MI-219 was more effective in upregulating wt-p53 stabilization compared to Nutlin-3. MI-219, but not Nutlin-3, enhanced the autoubiquitination and degradation of HDM2.

Conclusions

Our data reveals unexpected differences between MI-219 and the well-studied Nutlin-3 in lymphoma cell lines and patient samples. We suggest a novel mechanism for MI-219 that alters the functional activity of HDM2 through enhanced autoubiquitination and degradation. Additionally, this mechanism appears to correspond to biological outcome. Our results provide evidence that different classes of HDM2 SMIs elicit molecular events that extend beyond HDM2-p53 dissociation which may be of biological and potentially therapeutic importance.

A phase I dose-escalation trial of high-dose melphalan with palifermin for cytoprotection followed by autologous stem cell transplantation for patients with multiple myeloma with normal renal function

Melphalan 200 mg/m(2) is the standard conditioning regimen for patients with multiple myeloma (MM) with normal renal function (NRF) undergoing autologous stem cell transplant (ASCT). In an effort to escalate the dose of melphalan and to improve the efficacy, we designed a dose-escalation study of melphalan in conjunction with palifermin in patients with NRF, with the hope that a higher dose of melphalan can be administered with an acceptable degree of oral mucositis (OM). We enrolled 19 patients (18 evaluable) with NRF. Dose-escalation of melphalan administered on day -2 began at 200 mg/m(2) with palifermin administered at a fixed dose of 60 mcg/kg/day. Palifermin was given as an i.v. bolus on day -5, -4, and -3, and then on day +1, +2, and +3. Subsequent dose escalations of melphalan were done at 20 mg/m(2) increments up to a maximum dose of 280 mg/m(2). Of 18 evaluable patients, there were no treatment-related deaths by day 100. The median age was 48.5 years (range, 33-65 years). The most common adverse events related to palifermin included rash (18 events, no ≥ grade 3 events), elevation of amylase (10 events, 4 were grade 3 but asymptomatic), and lipase (5 events, 2 were grade 3 but asymptomatic), edema (11 events, no ≥ grade 3). The overall incidence of OM grade 3 was 44% (8/18) with a median duration of severe mucositis of 5 days (range, 3-6 days). Eleven patients (61%) required opioid analgesics. None of the patients received total parenteral nutrition (TPN)/nasogastric feeding. Two of 6 patients who were given melphalan 280 mg/m(2) did not develop OM. Cardiac dose-limiting toxicity (DLT) in the form of atrial fibrillation did occur in 1 of 6 patients treated with melphalan 280 mg/m(2). Palifermin has permitted safe dose escalation of melphalan up to 280 mg/m(2), thus reaching the cumulative dosage of melphalan administered in tandem ASCT. This higher dose of melphalan has the potential to improve the efficacy and, hopefully, outcomes of patients with MM with a single ASCT. A phase 2 trial is necessary to better delineate the antimyeloma efficacy of this regimen.

[Local use of tranexamic acid in ENT surgery]

Bleeding is a main complication in ENT surgery especially in oral and nasal interventions. Based on good results in local application of tranexamic acid after dental extraction, the different possibilities of local application of tranexamic acid in ENT surgery are discussed and the current literature is presented. In our experience, the rate of secondary hemorrhage after oral and nasal interventions can be reduced considerably by local application of tranexamic acid, which means risk reduction and better compliance especially in an increasingly aging patient population. Based on our experience, the local use of tranexamic acid in ENT surgery should be the focus of future studies.

ERLIN2 promotes breast cancer cell survival by modulating endoplasmic reticulum stress pathways

Background

Amplification of the 8p11-12 region has been found in approximately 15% of human breast cancer and is associated with poor prognosis. Previous genomic analysis has led us to identify the endoplasmic reticulum (ER) lipid raft-associated 2 (ERLIN2) gene as one of the candidate oncogenes within the 8p11-12 amplicon in human breast cancer, particularly in the luminal subtype. ERLIN2, an ER membrane protein, has recently been identified as a novel mediator of ER-associated degradation. Yet, the biological roles of ERLIN2 and molecular mechanisms by which ERLIN2 coordinates ER pathways in breast carcinogenesis remain unclear.

Methods

We established the MCF10A-ERLIN2 cell line, which stably over expresses ERLIN2 in human nontransformed mammary epithelial cells (MCF10A) using the pLenti6/V5-ERLIN2 construct. ERLIN2 over expressing cells and their respective parental cell lines were assayed for in vitro transforming phenotypes. Next, we knocked down the ERLIN2 as well as the ER stress sensor IRE1α activity in the breast cancer cell lines to characterize the biological roles and molecular basis of the ERLIN2 in carcinogenesis. Finally, immunohistochemical staining was performed to detect ERLIN2 expression in normal and cancerous human breast tissues

Results

We found that amplification of the ERLIN2 gene and over expression of the ERLIN2 protein occurs in both luminal and Her2 subtypes of breast cancer. Gain- and loss-of-function approaches demonstrated that ERLIN2 is a novel oncogenic factor associated with the ER stress response pathway. The IRE1α/XBP1 axis in the ER stress pathway modulated expression of ERLIN2 protein levels in breast cancer cells. We also showed that over expression of ERLIN2 facilitated the adaptation of breast epithelial cells to ER stress by supporting cell growth and protecting the cells from ER stress-induced cell death.

Conclusions

ERLIN2 may confer a selective growth advantage for breast cancer cells by facilitating a cytoprotective response to various cellular stresses associated with oncogenesis. The information provided here sheds new light on the mechanism of breast cancer malignancy

Hypogonadism in patients with sickle cell disease: central or peripheral?

There is conflicting evidence in the literature on the etiology of hypogonadism in patients with sickle cell disease (SCD). A cross-sectional study was done to determine whether hypogonadism in male patients with SCD is due to primary testicular failure or secondary pituitary/hypothalamic dysfunction and assess the association between hypogonadism and serum ferritin levels. Hormonal assessment for serum concentrations of testosterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH) was done for 34 men with SCD and their charts were reviewed for relevant clinical variables. Eight men (24%) were classified hypogonadal based on their serum testosterone levels. These men have significantly lower LH (p = 0.001) and FSH (p = 0.01) levels than normogonadal men, indicating a central etiology. There was no significant difference between hypogonadal and normogonadal men with respect to ferritin levels (p = 0.71). Our study indicates a central etiology of hypogonadism in patients with SCD. In this small study ferritin level was not significantly related to hypogonadism.

Phase I trial of bortezomib during maintenance phase after high dose melphalan and autologous stem cell transplantation in patients with multiple myeloma

We enrolled 15 patients in this phase I dose de-escalation trial. Twelve patients are evaluable. The primary objective was to determine the safest and best tolerated maintenance dosing (MD) of bortezomib (B). The secondary endpoints were to evaluate complete response (CR), overall response (OR) and response duration. All patients receiving autologous stem cell transplant (ASCT) were eligible and registered between D+30 to D+120 after ASCT. A maximum number of 8 cycles of B was planned. Two evaluable patients in level (L) 1 received therapeutic dose of B 1.3 mg/m(2) intravenously on days (D) 1, 4, 8, and 11 in a 21 day cycle. Both these patients experienced dose limiting toxicities (DLTs). Four evaluable patients were then enrolled in dose L2 utilizing B 1.3 mg/m(2) on D 1, 4, 8, and 11 in a 28 day cycle. Two patients in L2 developed DLTs. Six evaluable patients were thereafter enrolled in L3 utilizing B 1 mg/m(2) on D 1, 8, and 15 in a 28 day cycle. Median 8 cycles of B were administered (2-8). No DLTs were observed in L3. The median duration of follow up for the entire cohort is 33 months (12-62). The median duration of response in L3 is 29.1 months (12-33). We conclude that B 1 mg/m(2) administered intravenously and may be subcutaneously on D 1, 8, and 15 in a 28 day cycle is the best tolerated MD and can be safely given beginning around D+100 post-ASCT.

Effect of lenalidomide induction therapy on peripheral blood stem cell collection in patients undergoing autologous stem cell transplant for multiple myeloma

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Background: Autologous stem cell transplant (ASCT) remains part of standard therapy for Multiple Myeloma (MM). Lenalidomide (LEN) is a newer, effective therapy for MM. It has been suggested that prior LEN therapy is associated with an increased risk of stem cell collection failure, particularly when only G-CSF is used for mobilization. Methods: We conducted a retrospective chart review of 310 consecutive MM pts who underwent pheresis to collect stem cells for first ASCT between July 1, 2007 and June 30, 2011 at the Karmanos Cancer Institute. We compared differences in quantity of CD34 cells collected, days needed to collect the target number of cells (> 2.5 x 10*6 CD34+ cells/kg), days to platelet and neutrophil engraftment. We also evaluated the association between CD34+ cells collected and the number of cycles of LEN therapy. Results: Of 310 patients, 90% were mobilized with only G-CSF initially. Patients were analyzed as two groups: LEN exposed (LEN(+); n = 128) and LEN naive(LEN(-); n = 182). Median age in both groups was 58 years. No differences in race, sex and MM stage distribution were observed between the two groups. The median number of stem cells collected in the LEN(+) group was significantly less than the LEN(-) group (6.46 vs. 7.56 x 10*6 CD34 cells/kg; p= 0.0004). In addition, the median number of pheresis sessions required for adequate stem cell collection were significantly more in the LEN(+)group as compared to LEN(-) group (2 vs.1 sessions; p=0.002). In the LEN(+) group, there was a negative correlation between CD34+ cells collected and the prior number of cycles of LEN (p=0.0001). There was no statistically significant excess in the number of stem cell collection failures with G-CSF in the LEN(+) group (7% vs. 4% p=0.31). All pts who failed collection after G-CSF were successfully collected with Cytoxan or Plerixafor priming. LEN exposure had no effect on post-ASCT neutrophil or platelet recovery. Conclusions: Although Lenalidomide exposure is associated with a slightly lower CD34+ stem cell yield and on average an extra session of pheresis when G-CSF is used for mobilization, collection failure is uncommon and post-ASCT engraftment is normal.

Induction of proapoptotic antibodies to triple-negative breast cancer by vaccination with TRAIL death receptor DR5 DNA

TNF-related apoptosis-inducing ligand receptor 2 [TRAIL-R2 or death receptor 5 (DR5)] is expressed at elevated levels in a broad range of solid tumors to mediate apoptotic signals from TRAIL or agonist antibodies. We tested the hypothesis that DR5 DNA vaccination will induce proapoptotic antibody to trigger apoptosis of tumor cells. BALB/c mice were electrovaccinated with DNA-encoding wild-type human DR5 (phDR5) or its derivatives. Resulting immune serum or purified immune IgG induced apoptosis in triple-negative breast cancer (TNBC) cells, which were also TRAIL sensitive. The proapoptotic activity of immune serum at dilutions of 0.5-2% was comparable to that of 1-2 μg/ml of TRAIL. Apoptotic activity of immune serum was enhanced by antibody crosslinking. Apoptotic cell death induced by anti-DR5 antibody was shown by the cleavage of PARP and caspase-3. In contrast, immune serum had no effect on the proliferation of activated human T cells, which expressed low levels of DR5. In vivo, hDR5 reactive immune serum prevented growth of SUM159 TNBC cells in severe combined immune-deficient mice. DR5-specific IFN-γ-secreting T cells were also induced by DNA vaccination. Furthermore, the feasibility to overcome immune tolerance to self DR5 was shown by the induction of mouse DR5-binding antibody after electrovaccination of BALB/c mice with pmDR5ectm-Td1 encoding a fusion protein of mouse DR5 and an immunogenic fragment of tetanus toxin. These findings support DR5 as a promising vaccine target for controlling TNBC and other DR5-positive cancers.

Melphalan 180 mg/m2 can be safely administered as conditioning regimen before an autologous stem cell transplantation (ASCT) in multiple myeloma patients with creatinine clearance 60 mL/min/1.73 m2 or lower with use of palifermin for cytoprotection: results of a phase I trial

High-dose melphalan 140 mg/m2 is the standard of care for patients with multiple myeloma (MM) with renal insufficiency (RI). Palifermin as a cytoprotective agent has demonstrated efficacy in reducing the intensity and duration of oral mucositis (OM) in patients who receive intensive chemotherapy/radiotherapy. There is no prospective data on the use of palifermin in patients with MM with RI.

ELIGIBILITY CRITERIA

creatinine clearance ≤60 mL/minute/1.73 m2, age >18 years, no dialysis, no active OM, and a suitable candidate for autologous stem cell transplant (ASCT). Melphalan dose ranged from 140 to 200 mg/m2 and escalated at the increment of 20 mg/m2. Six dosages of palifermin 60 mcg/kg/day were given intravenously between day -5 to day +3. Dose escalations were to stop if dose-limiting toxicities (DLTs) occurred at melphalan dose in ≥2 of 3 patients, with that dose declared as the maximal administered dose and the level below where ≤1 of 6 patients had DLTs was considered the maximally tolerated dose (MTD). Nineteen patients were enrolled from June 2007 to June 2011. Data on 15 evaluable patients is reported as 4 patients were removed. Median age was 59 years (range, 36-67 years). The overall incidence of OM ≥ grade 3 was 53% (8 of 15) and a median duration of ≥grade 3 OM was 6.5 days (range, 3-42 days). One patient in L2 (melphalan 160 mg/m2) developed atrial fibrillation on day +9. Two patients in L4 (melphalan 200 mg/m2) developed grade 4 OM, hence reaching DLT. No DLT was observed in 6 patients enrolled in L3 (melphalan 180 mg/m2). Palifermin has permitted safe dose escalation of melphalan up to 180 mg/m(2) in patients with RI.