Patient-reported experience with hypoglossal nerve stimulation in the treatment of obstructive sleep apnea

BACKGROUND

Breathing-synchronized hypoglossal nerve stimulation (HNS) is routinely used as an alternative treatment for patients with obstructive sleep apnea (OSA). Significant and clinically relevant improvements in disease severity and OSA symptoms such as daytime sleepiness as well as overall quality of life have been reported in randomized-controlled trials and large real-world cohort studies. However, so far, few data exist on patient-reported experience with the treatment.

METHODS

A structured survey with 22 questions was constructed using five-level Likert scales (1 = no agreement, 5 = complete agreement) to evaluate patient experience with HNS and perception of the treatment in the domains "Overall experience with therapy," "Experience with treatment process," and "Side-effects from treatment." Additional data were collected on current symptom status, measured with Epworth sleepiness scale (ESS) questionnaire, and OSA disease history. Multiple linear regression analysis was conducted to test associations of medical variables and response behavior. Correlations between variables and domains, as well as individual items, were assessed using Spearman rank test.

RESULTS

A total of 75 patients from Germany who were treated with breathing-synchronized HNS were enrolled (mean age 57.3 years, 78% male), and 71 questionnaires with complete data were included for analysis. Two-thirds of participants (67%) had a history of OSA history for 5 years or longer. Of all patients, 76% had normalized OSA symptoms at time of the study (ESS: 6.4 ± 5.0) and 98% reported using stimulation therapy every night. Regression analysis revealed an association of current symptoms measured with ESS and response behavior. Hence, patients with normalized daytime sleepiness reported significantly more positive experience across all domains assessed, compared to patients with residual daytime sleepiness. Overall, only 2% of participants reported side effects that made them reduce or discontinue stimulation therapy. The rate of reported side effects was associated with current symptom control under therapy.

CONCLUSIONS

Overall patient-reported experience with breathing-synchronized HNS therapy was positive and high satisfaction with the treatment process was observed. Side effects occurred, but rarely affected subjective use of the therapy or satisfaction. Subjective experience and perception are influenced by residual daytime sleepiness with stimulation therapy.

Tunable Syngas Formation at Industrially Relevant Current Densities via CO2 Electroreduction and Hydrogen Evolution over Ni and Fe-derived Catalysts obtained via One-Step Pyrolysis of Polybenzoxazine Based Composites

Simultaneous electroreduction of CO2 and H2 O to syngas can provide a sustainable feed for established processes used to synthesize carbon-based chemicals. The synthesis of MOx /M-N-Cs (M = Ni, Fe) electrocatalysts reported via one-step pyrolysis that shows increased performance during syngas electrosynthesis at high current densities with adaptable H2 /CO ratios, e.g., for the Fischer-Tropsch process. When embedded in gas diffusion electrodes (GDEs) with optimized hydrophobicity, the NiOx /Ni-N-C catalyst produces syngas (H2 /CO = 0.67) at -200 mA cm-2 while for the FeOx /Fe-N-C syngas production occurs at ≈-150 mA cm-2 . By tuning the electrocatalyst's microenvironment, stable operation for >3 h at -200 mA cm-2 is achieved with the NiOx /Ni-N-C GDE. Post-electrolysis characterization revealed that the restructuring of the catalyst via reduction of NiOx to metallic Ni NPs still enables stable operation of the electrode at -200 mA cm-2 , when embedded in an optimized microenvironment. The ionomer and additives used in the catalyst layer are important for the observed stable operation. Operando Raman measurements confirm the presence of NiOx during CO formation and indicate weak adsorption of CO on the catalyst surface.

Combined stent retriever angioplasty and continuous intra-arterial nimodipine infusion as salvage therapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage: illustrative case

BACKGROUND

Delayed cerebral ischemia (DCI) and cerebral vasospasm (CV) are severe complications of spontaneous subarachnoid hemorrhage (SAH) contributing to an inferior outcome. Rescue therapies include intra-arterial balloon angioplasty and repetitive and finally continuous intra-arterial nimodipine infusion.

OBSERVATIONS

In the presented case, a young female patient with fulminant refractory DCI and CV, despite induced hypertension and nimodipine application, was treated with three-vessel continuous intra-arterial infusion and additional repetitive angioplasty of the basilar and middle cerebral arteries using a stent retriever, leading to a good clinical outcome. Additional stent retriever dilatation to continuous intra-arterial nimodipine application in three vessel territories may represent a further escalation step in the rescue therapy for severe CV and DCI after SAH. Montreal Cognitive Assessment and SF-36 testing showed satisfactory results 3 months after initial treatment with intra-arterial nimodipine catheters in three vessel territory circulations and additional stent retriever vasodilation of severe CV.

LESSONS

We report a unique rescue strategy involving implantation of an additional intra-arterial catheter into the vertebral artery and repetitive stent retriever dilatations of the middle cerebral and basilar arteries as an extra therapy for continuous intra-arterial nimodipine vaspospasmolytic therapy in three vessel territories, resulting in a very good clinical outcome.

Defining a role for systemic chemotherapy in local and advanced appendix adenocarcinoma

BACKGROUND

Appendix adenocarcinomas (AAs) are rare tumours that often present late, with a propensity for peritoneal metastases (PMs). This study aimed to evaluate outcomes of AA patients undergoing cytoreductive surgery (CRS) with curative intent and determine the role of systemic chemotherapy.

MATERIALS AND METHODS

Data were collected from a prospective database and classified according to World Health Organization (WHO) 2019 classification. Tumour clearance from CRS was described using a completeness of cytoreduction (CC) score ranging from 0 [no residual disease (RD)] to 3 (>2.5 cm RD). Patients with CC0-2 CRS received hyperthermic intraperitoneal chemotherapy (HIPEC). Systemic chemotherapy was categorised as 'prior' (>6 months before), 'neoadjuvant' (<6 months before), 'adjuvant' (<6 months after CC0-1 CRS) or 'palliative' (after CC2-3 CRS). Analyses used Kaplan-Meier and Cox regression methods.

RESULTS

Between January 2005 and August 2021, 216 AA patients were identified for inclusion. Median age was 59 years (21-81 years). CRS/HIPEC was carried out in 182 (84%) patients, of whom 164/182 (76%) had mitomycin C HIPEC. CC0-1 was achieved in 172 (80%) patients. Systemic chemotherapy was given to 97 (45%) patients from the whole cohort and to 37/46 (80%) patients with positive nodes. Median overall survival (OS) was 122 months (95% confidence interval 61-182 months). After multivariate analysis, patients with acellular and lower-grade PM had similar OS to those with localised (M0) disease (P = 0.59 and P = 0.19). For patients with positive nodes, systemic chemotherapy was associated with reduced risk of death compared to no chemotherapy (P < 0.0019).

CONCLUSION

This study identifies AA patients with positive lymph nodes derive the most benefit from systemic chemotherapy. We confirm the prognostic importance of stage and peritoneal grade, with excellent outcomes in patients with acellular mucin and lower-grade PM.

Nab-paclitaxel weekly versus dose-dense solvent-based paclitaxel followed by dose-dense epirubicin plus cyclophosphamide in high-risk HR+/HER2- early breast cancer: results from the neoadjuvant part of the WSG-ADAPT-HR+/HER2- trial

BACKGROUND

In high-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) early breast cancer (EBC), nanoparticle albumin-bound (nab)-paclitaxel showed promising efficacy versus solvent-based (sb)-paclitaxel in neoadjuvant trials; however, optimal patient and therapy selection remains a topic of ongoing research. Here, we investigate the potential of Oncotype DX® recurrence score (RS) and endocrine therapy (ET) response (low post-endocrine Ki67) for therapy selection.

PATIENTS AND METHODS

Within the WSG-ADAPT trial (NCT01779206), high-risk HR+/HER2- EBC patients were randomized to (neo)adjuvant 4× sb-paclitaxel 175 mg/m2 q2w or 8× nab-paclitaxel 125 mg/m2 q1w, followed by 4× epirubicin + cyclophosphamide (90 mg + 600 mg) q2w; inclusion criteria: (i) cN0-1, RS 12-25, and post-ET Ki67 >10%; (ii) cN0-1 with RS >25. Patients with cN2-3 or (G3, baseline Ki67 ≥40%, and tumor size >1 cm) were allowed to be included without RS and/or ET response testing. Associations of key factors with pathological complete response (pCR) (primary) and survival (secondary) endpoints were analyzed using statistical mediation and moderation models.

RESULTS

Eight hundred and sixty-four patients received neoadjuvant nab-paclitaxel (n= 437) or sb-paclitaxel (n = 427); nab-paclitaxel was superior for pCR (20.8% versus 12.9%, P = 0.002). pCR was higher for RS >25 versus RS ≤25 (16.0% versus 8.4%, P = 0.021) and for ET non-response versus ET response (15.1% versus 6.0%, P = 0.027); no factors were predictive for the relative efficacy of nab-paclitaxel versus sb-paclitaxel. Patients with pCR had longer distant disease-free survival [dDFS; hazard ratio 0.42, 95% confidence interval (CI) 0.20-0.91, P = 0.024]. Despite favorable prognostic association of RS >25 versus RS ≤25 with pCR (odds ratio 3.11, 95% CI 1.71-5.63, P ≤ 0.001), higher RS was unfavorably associated with dDFS (hazard ratio 1.03, 95% CI 1.01-1.05, P = 0.010).

CONCLUSIONS

In high-risk HR+/HER2- EBC, neoadjuvant nab-paclitaxel q1w appears superior to sb-paclitaxel q2w regarding pCR. Combining RS and ET response assessment appears to select patients with highest pCR rates. The disadvantage of higher RS for dDFS is reduced in patients with pCR. These are the first results from a large neoadjuvant randomized trial supporting the use of RS to help select patients for neoadjuvant chemotherapy in high-risk HR+/HER2- EBC.

Adjuvant Therapy for Elderly Breast Cancer Patients after Breast-Conserving Surgery: Outcomes in Real World Practice

We aimed to evaluate the standard of care of adjuvant radiotherapy (RT) after breast-conserving surgery (BCS) in elderly female patients (≥65 years) treated outside of clinical trials and to identify potential factors related to the omission of RT and the interaction with endocrine therapy (ET). All women treated with BCS at two major breast centers between 1998 and 2014 were evaluated. Data were provided by the Tumor Registry Munich. Survival analyses were conducted using the Kaplan-Meier method. Prognostic factors were identified using multivariate Cox regression analysis. The median follow-up was 88.4 months. Adjuvant RT was performed in 82% (2599/3171) of patients. Irradiated patients were younger (70.9 vs. 76.5 years, p < 0.001) and were more likely to receive additional chemotherapy (p < 0.001) and ET (p = 0.014). Non-irradiated patients more often had non-invasive DCIS tumors (pTis: 20.3% vs. 6.8%, p < 0.001) and did not undergo axillary surgery (no axillary surgery: 50.5% vs. 9.5%, p < 0.001). Adjuvant RT was associated with improved locoregional tumor control after BCS in invasive tumors (10-year local recurrence-free survival (LRFS): 94.0% vs. 75.1%, p < 0.001, 10-year lymph node recurrence-free survival (LNRFS): 98.1% vs. 93.1%, p < 0.001). Multivariate analysis confirmed significant benefits for local control with postoperative RT. Furthermore, RT led to increased locoregional control even in patients who received ET (10-year LRFS 94.8% with ET + RT vs. 78.1% with ET alone, p < 0.001 and 10-year LNRFS: 98.2% vs. 95.0%, p = 0.003). Similarly, RT alone had significantly better locoregional control rates compared to ET alone (10-year LRFS 92.6% with RT alone vs. 78.1% with ET alone, p < 0.001 and 10-year LNRFS: 98.0% vs. 95.0%, p = 0.014). The present work confirms the efficacy of postoperative RT for breast carcinoma in elderly patients (≥65 years) treated in a modern clinical setting outside of clinical trials, even in patients who receive ET.

Functional MRI in neuro-urology: A narrative review

Neuro-imaging has given urologists a new tool to investigate the neural control of the lower urinary tract. Using functional magnetic resonance imaging (fMRI), it is now possible to understand which areas of the brain contribute to the proper function of the storage and voiding of the lower urinary tract. This field of research has evolved from simple anatomical descriptions to elucidating the complex micturition network. A keyword search of the Medline database was conducted by two reviewers for relevant studies from January 1, 2010, to August 2022. Of 2047 peer-reviewed articles, 49 are included in this review. In the last decade, a detailed understanding of the brain-bladder network has been described, elucidating a dedicated network, as well as activated areas in the brainstem, cerebellum, and cortex that share reproducible connectivity patterns. Research has shown that various urological diseases can lead to specific changes in this network and that therapies used by urologists to treat lower urinary tract symptoms (LUTS) are also able to modify neuronal activity. This represents a set of potential new therapeutic targets for the management of the lower urinary tract symptoms (LUTS). fMRI technology has made it possible to identify subgroups of responders to various treatments (biofeedback, anticholinergic, neuromodulation) and predict favourable outcomes. Lastly, this breakthrough understanding of neural control over bladder function has led to treatments that directly target brain regions of interest to improve LUTS. One such example is the use of non-invasive transcranial neuromodulation to improve voiding symptoms in individuals with multiple sclerosis.

Protocol for the CoNoR Study: A prospective multi-step study of the potential added benefit of two novel assessment tools in colorectal liver metastases technical resectability decision-making

INTRODUCTION

Liver resection is the only curative treatment for colorectal liver metastases (CLM). Resectability decision-making is therefore a key determinant of outcomes. Wide variation has been demonstrated in resectability decision-making, despite the existence of criteria. This paper summarises a study protocol to evaluate the potential added value of two novel assessment tools in assessing CLM technical resectability: the Hepatica preoperative MR scan (MR-based volumetry, Couinaud segmentation, liver tissue characteristics and operative planning tool) and the LiMAx test (hepatic functional capacity).

METHODS AND ANALYSIS

This study uses a systematic multistep approach, whereby three preparatory workstreams aid the design of the final international case-based scenario survey:Workstream 1: systematic literature review of published resectability criteria.Workstream 2: international hepatopancreatobiliary (HPB) interviews.Workstream 3: international HPB questionnaire.Workstream 4: international HPB case-based scenario survey.The primary outcome measures are change in resectability decision-making and change in planned operative strategy, resulting from the novel test results. Secondary outcome measures are variability in CLM resectability decision-making and opinions on the role for novel tools.

ETHICS AND DISSEMINATION

The study protocol has been approved by a National Health Service Research Ethics Committee and registered with the Health Research Authority. Dissemination will be via international and national conferences. Manuscripts will be published.

REGISTRATION DETAILS

The CoNoR Study is registered with ClinicalTrials.gov (registration number NCT04270851). The systematic review is registered on the PROSPERO database (registration number CRD42019136748).

Spray-Flame Synthesis of LaFexCo1-xO3 (x = 0.2, 0.3) Perovskite Nanoparticles for Oxygen Evolution Reaction in Water Splitting: Effect of Precursor Chemistry (Acetates and Nitrates)

The product properties of mixed oxide nanoparticles generated via spray-flame synthesis depend on an intricate interplay of solvent and precursor chemistries in the processed solution. The effect of two different sets of metal precursors, acetates and nitrates, dissolved in a mixture of ethanol (35 Vol.%) and 2-ethylhexanoic acid (2-EHA, 65 Vol.%) was investigated for the synthesis of LaFe_xCo_1-xO₃ (x = 0.2, 0.3) perovskites. Regardless of the set of precursors, similar particle-size distributions (d_p = 8-11 nm) were obtained and a few particles with sizes above 20 nm were identified with transmission electron microscopy (TEM) measurements. Using acetates as precursors, inhomogeneous La, Fe, and Co elemental distributions were obtained for all particle sizes according to energy dispersive X-ray (EDX) mappings, connected to the formation of multiple secondary phases such as oxygen-deficient La₃(Fe_xCo_1-x)₃O₈ brownmillerite or La₄(Fe_xCo_1-x)₃O₁₀ Ruddlesden-Popper (RP) structures besides the main trigonal perovskite phase. For samples synthesized from nitrates, inhomogeneous elemental distributions were observed for large particles only where La and Fe enrichment occurred in combination with the formation of a secondary La₂(Fe_xCo_1-x)O₄ RP phase. Such variations can be attributed to reactions in the solution prior to injection in the flame as well as precursor-dependent variations in in-flame reactions. Therefore, the precursor solutions were analyzed by temperature-dependent attenuated total reflection Fourier-transform infrared (ATR-FTIR) measurements. The acetate-based precursor solutions indicated the partial conversion of, mainly La and Fe, acetates to metal 2-ethylhexanoates. In the nitrate-based solutions, esterification of ethanol and 2-EHA played the most important role. The synthesized nanoparticle samples were characterized by BET (Brunauer, Emmett, Teller), FTIR, Mössbauer, and X-ray photoelectron spectroscopy (XPS). All samples were tested as oxygen evolution reaction (OER) catalysts, and similar electrocatalytic activities were recorded when evaluating the potential required to reach 10 mA/cm² current density (∼1.61 V vs reversible hydrogen electrode (RHE)).

Abstract PD4-02: PD4-02 Spatial and temporal heterogeneity of predictive and prognostic signatures in triple-negative breast cancer treated with neoadjuvant combination immune-chemotherapy

Background: It is well known that immunological pathways are relevant for response to classical neoadjuvant chemotherapy as well as combined chemo-immunotherapy. In addition, it has been shown that combined chemo-immunotherapy significantly improves survival, even in the context of only moderate effects on pCR. Due to the window therapy with durvalumab-alone and the option to analyze multiple consecutive biopsies, the GeparNuevo trial offers the opportunity to 1) determine gene expression patterns for pCR and DDFS endpoints 2) identify pathways most relevant for pCR and DDFS 3) identify genes specifically regulated by immunotherapy (comparison of samples pre-and post-window) 4) identify genes specifically regulated by chemotherapy (comparison of samples pre-Tx and after 4 cycles of chemotherapy 5) identify longitudinal patterns of gene expression by comparison of up to four time points and 6) identify changes in the tumor microenvironment by spatial sequencing of tumor cell and stroma areas. Methods: 292 tumor samples were evaluated by gene expression analysis: 162 pretherapeutic core biopsies, 79 post-window biopsies, 32 biopsies during chemotherapy and 19 biopsies of the residual tumor after therapy. These samples were analyzed by HTG OBP panel targeting 2549 genes which are assigned to 25 different biological mechanisms or cellular pathways. In addition, spatial profiling was compared in a subset of pre-and post-window samples using Nanostring GeoMx spatial profiling system. Endpoints were pCR and DDFS. Results: A total of more than 600 genes were significantly associated with either the pCR or the DDFS endpoint in either the complete GeparNuevo cohort or one of the two therapy arms. Interestingly, there was a large number of predictive or prognostic genes (n=247 for pCR and n=179 for DDFS) in the durvalumab arm, while the number of genes in the placebo arm was considerably lower (n=113 for pCR and n=61 for DDFS). We used existing pathway information for HTG OBP panel to analyze the contribution of different cellular processes to pCR and DDFS signatures in different therapy arms. Immune pathways were particularly relevant for durvalumab signatures (pCR and DDFS), while cell cycle related gene expression patterns were particularly involved in signatures predictive of pCR in both therapy arms. To further assign genes to the cellular response to durvalumab-alone or chemotherapy-alone, we compared gene expression patterns in durvalumab arm before and after the window phase (gene expression patterns induced by one dose of durvalumab) with gene expression patterns in placebo arm before and after 4 cycles of chemotherapy. Further longitudinal alterations were analyzed by comparison of longitudinal samples for 4 different time-points (a: before NACT, n=162; b: after window phase, n=79; c: after 4 cycles, n=31 and d: at surgery, n=19). Using the Nanostring GeoMx spatial RNA profiling system guided by cytokeratine immunofluorescence, we compared areas with high tumor cell content with stromal areas with or without TILs. In combination with the HTG gene expression data, we were able allocate the changes induced by durvalumab vs chemotherapy to the stromal cell and tumor cell compartment, indicating a re-organization of the tumor-microenvironment. Conclusions: In our analysis, we show that immune gene signatures are particularly relevant for neoadjuvant response to durvalumab as well as prognosis after durvalumab treatment, while proliferation signatures are involved in pCR-signatures after durvalumab as well as chemotherapy. The spatial analysis showed that relevant changes occur in the stromal compartment, indicating a re-organization of the tumor microenvironment. The parallel targeting of immune- and proliferation pathways might explain why a combined immunotherapy-chemotherapy approach is more successful than each single therapy strategy alone.

Citation Format: Carsten Denkert, Andreas Schneeweiss, Julia Rey, Akira Hattesohl, Thomas Karn, Michael Braun, Paul Jank, Jens Huober, Hans-Peter Sinn, Dirk-Michael Zahm, Claus Hanusch, Frederik Marmé, Jenny Furlanetto, Jörg Thomalla, Jens-Uwe Blohmer, Marion van Mackelenbergh, Thorsten Stiewe, Peter Staib, Christian Jackisch, Julia Teply-Szymanski, Peter A. Fasching, Bruno V. Sinn, Michael Untch, Karsten Weber, Sibylle Loibl. PD4-02 Spatial and temporal heterogeneity of predictive and prognostic signatures in triple-negative breast cancer treated with neoadjuvant combination immune-chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD4-02.

Abstract PD11-03: PD11-03 Comparison of a mono Atezolizumab window followed by Atezolizumab and chemotherapy with Atezolizumab and chemotherapy in triple negative breast cancer – an interim analysis of the adaptive randomized neoadjuvant trial NeoMono

Introduction: Improvement of systemic treatment of TNBC represents an unmet medical need. Targeted therapy of regulatory immune pathways has become an important option in the treatment of many malignant diseases including breast cancer. Neodjuvant trials combining chemotherapy and checkpoint inhibitors (KEYNOTE-522 and IMpassion031) have demonstrated a meaningful benefit regarding pathological complete remission (pCR) for the addition of PD-1- or PD-L1-inhibitors to chemotherapy in patients with TNBC. In the KEYNOTE-522 trial, the addition of an immune checkpoint inhibitor (ICI) to neoadjuvant chemotherapy also had a beneficial impact on event-free survival even in patients who did not achieve a pCR. Of note, in the neoadjuvant GeparNuevo trial only those patients with TNBC who received a 2-week checkpoint inhibitor monotherapy window before the start of neoadjuvant chemotherapy in combination with checkpoint inhibition, achieved a significant pCR benefit from the addition of the PD-1 inhibitor Durvalumab to neoadjuvant chemotherapy alone. Methods: NeoMono is a phase 2 randomized multicenter trial recruiting male and female patients with primary TNBC (defined as ER/PR &lt; 10% and HER2 negative). Neoadjuvant treatment in Arm A and B consists of Atezolizumab 1200 mg every 3 weeks in addition to neoadjuvant chemotherapy (i.e., 12 x Carboplatin and Paclitaxel q1w followed by Epirubicin and Cyclophosphamide q3w). Combination therapy in arm A is preceded by an Atezolizumab monotherapy window (i.e., 840 mg Atezolizumab once two weeks prior to initiation of combination therapy). Study goals are to compare the efficacy of neoadjuvant chemotherapy with Atezolizumab with and without an Atezolizumab two-week monotherapy window (primary endpoint: pCR) and the identification of biomarkers predicting (early) response to or resistance against Atezolizumab. The extensive translational program of the neoMono trial aims at identifying these biomarkers on tumor and patient level through analysis of sequential tissue and liquid biopsies. The NeoMono statistical design adapts the idea of a proof-of-concept trial and uses Bayesian posterior and predictive probabilities for inference about the primary hypothesis. Up to four planned efficacy interim analyses provide decision points for early stopping for success or futility. The expected maximum number of patients to be recruited is 458. Results: The predefined number of 50 patients in each arm being evaluable for the primary endpoint pCR has been reached and the results of the first planned interim analysis will be presented at the meeting. Conclusion: The addition of an ICI to state of the art neoadjuvant chemotherapy has recently been established as a new standard of care in TNBC. NeoMono has the potential to answer the question if the beneficial effect of the ICI can be increased by a chemotherapy free ICI monotherapy window prior to a combination with neoadjuvant chemotherapy.

Citation Format: Hans-Christian Kolberg, Johannes Schumacher, Ramona Erber, Michael Braun, Bernhard Heinrich, Oliver Hoffmann, Peter A. Fasching, Georg Kunz, Michael P. Lux, Christian Schem, Eva-Maria Grischke, Mustafa Deryal, Kristina Lübbe, Arndt Hartmann, Sabine Kasimir-Bauer, Cornelia Kolberg-Liedtke. PD11-03 Comparison of a mono Atezolizumab window followed by Atezolizumab and chemotherapy with Atezolizumab and chemotherapy in triple negative breast cancer – an interim analysis of the adaptive randomized neoadjuvant trial NeoMono [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD11-03.

Abstract P5-02-03: Combined biomarker analysis for prediction of pathological complete response (pCR) after 12 weeks of pembrolizumab + trastuzumab + pertuzumab in HER2-enriched early breast cancer: Keyriched-1 trial

Background In unselected HER2+ early breast cancer (EBC), de-escalated chemotherapy-free neoadjuvant therapy (NAT) with dual HER2-blockade induces pCR rates of only 20%-40%. In order to achieve pCR rates by de-escalated therapy comparable to those achieved by chemotherapy-based regimens, patient selection and more effective chemotherapy-free regimens are thus key. KEYRICHED-1 (NCT03988036), a single-arm phase 2 study, is the first trial to investigate chemotherapy-free NAT with dual HER2 blockade and pembrolizumab in HER2-enriched HER2+ EBC. In a translational subproject, we analyzed gene signatures together with tumor cell proliferation and spatiotemporal immune cell profiling to identify predictive factors for pCR. Methods 48 pre- and postmenopausal patients with newly diagnosed HER2 2+ (ISH positive) or 3+ EBC (stage I-III) and HER2-enriched (HER2-E) subtype by PAM50 were included in the study. All patients received 4 cycles of pembrolizumab (200 mg), trastuzumab biosimilar ABP 980 (loading dose (LD) 8 mg/kg bodyweight (BW), maintenance dose (MD) 6 mg/kg BW), and pertuzumab (LD 840 mg/kg BW, MD 420 mg/kg BW) q21d. Primary objective was pCR (centrally confirmed absence of invasive tumor in breast and lymph nodes: ypT0/is, ypN0). NanoString Breast Cancer 360 panel was performed in baseline biopsies (n=42). ≥30% Ki67 decrease, &lt; 500 invasive tumor cells or no evidence of tumor in week 3 biopsies (on treatment) were classified as early response. sTILs were analyzed at baseline (n=42) and week 3 (n=28). Ongoing analyses include whole exome sequencing and multiplexed immunohistochemistry for expression of PD1, PDL1, CD4, CD8, CD68, and CD20 levels in tumor and stroma at baseline and at week 3. Impact of standardized expression of single genes, signatures, and sTILs on pCR was evaluated with univariable and multivariate logistic regression analyses and summarized with odds ratios (OR) and 95% confidence intervals (95%CI). Results 42 patients with BC360 and sTILs data at baseline were included in the analysis. Median age was 55 years (range: 22-83), 11 patients (31%) had node-positive EBC. At baseline, 28 patients had sTIL levels ≥30% and 14 had sTILs &lt; 30%; the corresponding pCR rates were 57.1% (n=16) and 28.6% (n=4, p=0.108). At week 3 (on treatment), 16 patients had sTIL levels ≥30%, 50% (n=8) had a pCR vs 8.3% in those with &lt; 30% sTILs (one patient out of 12, p=0.039). 37 patients had early response, 54.1% of them (n=20) had a pCR vs 0% in early non-responders (n=5, p=0.049). In univariate analysis, IDO1, ERBB2, IFNγ, cytotoxic cells, cytotoxicity, CD8 T-cells, TIGIT, and tumor inflammation signatures were statistically significantly associated with pCR (OR 2.3-3.6); ERBB2, IDO1, IFNγ and CD8 T-cells remained significant after adjusting for hormone receptor (HR) and central HER2 status (OR 2.2-4.3). 70 single genes were predictive for pCR; none of them remained significant after false discovery rate adjustment (25%). In multivariable analysis for baseline markers including signatures, sTILs, HR and central HER2 status, only ERBB2 (OR 8.7, 95%CI 1.9-39.0, p=0.0046) and cytotoxic cells signatures (OR 4.6, 95%CI 1.6-13.5, p=0.0059) were predictive for pCR. Results of whole exome sequencing, and multiplexed immunohistochemistry analysis of immune cell markers will be presented at the Symposium. Conclusions Biomarker analysis in the unique KEYRICHED-1 cohort revealed that early response at week 3, ERBB2 and immune related signatures as well as on-therapy sTIL levels predict pCR after a chemotherapy-free combination of immunotherapy and dual HER2 blockade in HER2-enriched EBC. These results pave the way for validation in larger de-escalation trials investigating short, chemotherapy-free regimens in selected patients with HER2+ EBC. Funding for this research was provided by MSD Sharp & Dohme GmbH.

Citation Format: Monika Graeser, Sherko Kuemmel, Oleg Gluz, Friedrich Feuerhake, Valery Volk, Daniel Ulbrich-Gebauer, Claudia Biehl, Mattea Reinisch, Athina Kostara9, Iris Scheffen, Kerstin Luedtke-Heckenkamp, Andreas Hartkopf, Felix Hilpert, Angela Kentsch, Carsten Ziske, Reinhard Depenbusch, Michael Braun, Jens-Uwe Blohmer, Christine zu Eulenburg, Matthias Christgen, Ronald Kates, Stephan Bartels, Hans-Heinrich Kreipe, Enrico Pelz, Peter Schmid, Nadia Harbeck. Combined biomarker analysis for prediction of pathological complete response (pCR) after 12 weeks of pembrolizumab + trastuzumab + pertuzumab in HER2-enriched early breast cancer: Keyriched-1 trial [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-02-03.

De-Escalated Neoadjuvant Trastuzumab-Emtansine With or Without Endocrine Therapy Versus Trastuzumab With Endocrine Therapy in HR+/HER2+ Early Breast Cancer: 5-Year Survival in the WSG-ADAPT-TP Trial

PURPOSE

Neoadjuvant chemotherapy is standard of care in human epidermal growth factor receptor 2-positive (HER2+) early breast cancer (EBC), irrespective of the hormone receptor status. Trastuzumab-emtansine (T-DM1), antibody-drug conjugate, is highly effective in HER2+ EBC; however, no survival data are available for de-escalated antibody-drug conjugate-based neoadjuvant therapy without conventional chemotherapy.

PATIENTS AND METHODS

In the WSG-ADAPT-TP (ClinicalTrials.gov identifier: NCT01779206) phase II trial, 375 centrally reviewed patients with hormone receptor-positive (HR+)/HER2+ EBC (clinical stage I-III) were randomly assigned to 12 weeks of T-DM1 with or without endocrine therapy (ET) or trastuzumab + ET once every 3 weeks (ratio 1:1:1). Adjuvant chemotherapy (ACT) omission was allowed in patients with pathologic complete response (pCR). In this study, we report the secondary survival end points and biomarker analysis. Patients who received at least one dose of study treatment were analyzed. Survival was analyzed using the Kaplan-Meier method, two-sided log-rank statistics, and Cox regression models stratified for nodal and menopausal status. P values < .05 were considered statistically significant.

RESULTS

T-DM1, T-DM1 + ET, and trastuzumab + ET induced similar 5-year invasive disease-free survival (iDFS; 88.9%, 85.3%, 84.6%; P_log-rank = .608) and overall survival rates (97.2%, 96.4%, 96.3%; P_log-rank = .534). Patients with pCR versus non-pCR had improved 5-year iDFS rates (92.7% v 82.7%; hazard ratio, 0.40; 95% CI, 0.18 to 0.85). Among the 117 patients with pCR, 41 did not receive ACT; 5-year iDFS rates were similar in those with (93.0%; 95% CI, 84.0 to 97.0) and without ACT (92.1%; 95% CI, 77.5 to 97.4; P_log-rank = .848). Translational research revealed that tumors with PIK3CA wild type, high immune marker expression, and luminal-A tumors (by PAM50) had an excellent prognosis with de-escalated anti-HER2 therapy.

CONCLUSION

The WSG-ADAPT-TP trial demonstrated that pCR after 12 weeks of chemotherapy-free de-escalated neoadjuvant therapy was associated with excellent survival in HR+/HER2+ EBC without further ACT. Despite higher pCR rates for T-DM1 ± ET versus trastuzumab + ET, all trial arms had similar outcomes because of mandatory standard chemotherapy after non-pCR. WSG-ADAPT-TP demonstrated that such de-escalation trials in HER2+ EBC are feasible and safe for patients. Patient selection on the basis of biomarkers or molecular subtypes may increase the efficacy of systemic chemotherapy-free HER2-targeted approaches.

Use of drug-induced sleep endoscopy in Germany-an analysis based on claims data

Background

Drug-induced sleep endoscopy (DISE) has recently gained relevance as a diagnostic tool for obstructive sleep apnea (OSA). However, it is unclear to what extent and in which patient cohorts DISE is used in Germany. With introduction of specific coding for this method in 2021 (Operationen- und Prozedurenschluessel, OPS code), usage can now be analyzed based on diagnosis-related groups (DRG) claims data.

Methods

Aggregated data from all inpatient DISE procedures conducted in German hospitals in 2021 were obtained from the publicly available Institut fuer das Entgeltsystem im Krankenhaus (InEK) database. Patient-relevant information as well as data on hospitals providing the examinations were exported and analyzed.

Results

Between January and December 2021, a total of 2765 DISE procedures were conducted and documented using the newly introduced specific code (1-611.01). Most patients were male (75.6%), in the age categories 30-39 (15.2%) and 40-49 years (17.2%), and presented with the lowest patient clinical complexity level (PCCL; class 0 = 81.88%). Pediatric use was rare (1.8%). Leading main diagnoses of patients were G47.31 (OSA) and J34.2 (deviation of nasal septum). The most common procedures conducted together with DISE were nasal surgery, and the examination was mostly provided in large public hospitals with more than 800 beds.

Conclusion

Though the OSA prevalence in Germany is high, use of DISE as a diagnostic tool is low and represented only 4.4% of cases with a main diagnosis of OSA in 2021. Since specific coding was only introduced in January 2021, trends cannot yet be identified. Noticeable is the frequent combination of DISE with nasal surgery, which is not obviously related to a diagnosis of OSA. Limitations of the study are mainly related to the underlying data, which are available for the inpatient sector only, and due to potentially limited use of the OPS code, which was introduced recently and might not be known to all hospitals.

Impact of RNA Signatures on pCR and Survival after 12-Week Neoadjuvant Pertuzumab plus Trastuzumab with or without Paclitaxel in the WSG-ADAPT HER2+/HR- Trial

PURPOSE

To identify associations of biological signatures and stromal tumor-infiltrating lymphocytes (sTIL) with pathological complete response (pCR; ypT0 ypN0) and survival in the Phase II WSG-ADAPT HER2+/HR- trial (NCT01817452).

EXPERIMENTAL DESIGN

Patients with cT1-cT4c, cN0-3 HER2+/HR- early breast cancer (EBC) were randomized to pertuzumab+trastuzumab (P+T, n = 92) or P+T+paclitaxel (n = 42). Gene expression signatures were analyzed in baseline biopsies using NanoString Breast Cancer 360 panel (n = 117); baseline and on-treatment (week 3) sTIL levels were available in 119 and 76 patients, respectively. Impacts of standardized gene expression signatures on pCR and invasive disease-free survival (iDFS) were estimated by logistic and Cox regression.

RESULTS

In all patients, ERBB2 [OR, 1.70; 95% confidence interval (CI), 1.08-2.67] and estrogen receptor (ER) signaling (OR, 1.72; 95% CI, 1.13-2.61) were favorable, whereas PTEN (OR, 0.57; 95% CI, 0.38-0.87) was unfavorable for pCR. After 60 months median follow-up, 13 invasive events occurred (P+T: n = 11, P+T+paclitaxel: n = 2), none following pCR. Gene signatures related to immune response (IR) and ER signaling were favorable for iDFS, all with similar HR about 0.43-0.55. These patterns were even more prominent in the neoadjuvant chemotherapy-free group, where additionally BRCAness signature was unfavorable (HR, 2.00; 95% CI, 1.04-3.84). IR signatures were strongly intercorrelated. sTILs (baseline/week 3/change) were not associated with pCR or iDFS, though baseline sTILs correlated positively with IR signatures.

CONCLUSIONS

Distinct gene signatures were associated with pCR versus iDFS in HER2+/HR- EBC. The potential role of IR in preventing recurrence suggests that patients with upregulated IR signatures could be candidates for de-escalation concepts in HER2+ EBC.

Influence of PLGA End Groups on the Release Profile of Dexamethasone from Ocular Implants

The present study deals with the development of dexamethasone (DM)-loaded implants using ester end-capped Resomer RG 502 poly(lactic acid-co-glycolic acid) (PLGA) (502), acid end-capped Resomer RG 502H PLGA (502H), and a 502H:502 mixture (3:1) via hot melt extrusion (HME). The prepared intravitreal implants (20 and 40% DM loaded in each PLGA) were thoroughly investigated to determine the effect of different end-capped PLGA and drug loading on the long-term release profile of DM. The implants were characterized for solid-state active pharmaceutical ingredient (APIs) using DSC and SWAXS, water uptake during stability study, the crystal size of API in the implant matrix using hot-stage polarized light microscopy, and in vitro release profile. The kinetics of PLGA release was thoroughly investigated using quantitative ¹H NMR spectroscopy. The polymorph of DM crystal was found to remain unchanged after the extrusion and stability study. However, around 3 times reduction in API particle size was observed after the HME process. The morphology and content uniformity of the RT-stored samples were found to be comparable to the initial implant samples. Interestingly, the samples (mainly 502H) stored at 40 °C and 75% RH for 30 d demonstrated marked deformation and a change in content uniformity. The rate of DM release was higher in the case of 502H samples with a higher drug loading (40% w/w). Furthermore, a simple digital in vitro DM release profile derived for the formulation containing a 3:1 ratio of 502H and 502 was comparable with the experimental release profile of the respective polymer mixture formulation. The temporal development of pores and/or voids in the course of drug dissolution, evaluated using μCT, was found to be a precursor for the PLGA release. Overall, the release profile of DM was found to be dependent on the PLGA type (independent of subtle changes in the formulation mass and diameter). However, the extent of release was found to be dependent on DM loading. Thus, the present investigation led to a thorough understanding of the physicochemical properties of different end-capped PLGAs and the underlying formulation microstructure on the release profile of a crystalline water-insoluble drug, DM, from the PLGA-based implant.

Cytoreductive surgery and HIPEC in colorectal cancer peritoneal metastases (CRPM): Real-world outcomes in systemic anticancer treatment–naïve patients

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Background: The role of heated intraperitoneal chemotherapy (HIPEC) in colorectal cancer peritoneal metastases (CRPM) is confounded by cytoreductive surgery (CRS) or receipt of peri-operative systemic anticancer therapy (SACT). Following Prodige-7, the role of Oxaliplatin HIPEC in addition to CRS has been debated. We evaluated a patient series undergoing CRS with Oxaliplatin (368mg/m2 for 30 mins) or Mitomycin C (MMC) (35mg/m2 for 90 mins) HIPEC stratified by extent of CRS and SACT. Methods: Data collected retrospectively from a prospective database of CRPM patients undergoing CRS +/- HIPEC at a single UK Peritoneal Tumour Centre included sex, primary tumour detail: site, TNM stage, SACT: adjuvant, peri-operative, operation details: peritoneal cancer index (PCI), cytoreductive score (CC), HIPEC agent, molecular profile: RAS, BRAFV600E, PIK3CA, microsatellite status, date of last follow-up or recurrence/death to 1st July 2022. Univariable and multivariable (MVA) analysis were performed for overall survival (OS) and recurrence free survival (RFS). Outcomes were compared among three patient groups: 1. all comers (all patients who underwent CRS +/- HIPEC), 2. CC0-1 (those who achieved CC0-1) and 3. SACT naïve (CC0-1 and no SACT pre-CRS, adjuvant SACT post primary resection allowed if completed > 6 months). Results: From April 2005 to April 2021, 409 patients received HIPEC: 271 (66%) MMC, 138 (34%) Oxaliplatin; 395 patients (97%) had CRPM (all comers); 336 (85%) achieved CC0-1; 187 (47%) were SACT naïve. Median OS for all comer, CC0-1 and SACT naïve groups were 39, 44 and 47 months respectively. MMC vs Oxaliplatin HIPEC median OS was 44 (95% CI 38-49) vs 50 (95% 40-60) months, p=0.3 in CC0-1. Median OS in SACT naïve was 46 (95% CI 34-58) vs 60 (95% CI 38-82) months, p=0.3. Oxaliplatin HIPEC showed a trend to benefit PCI <15 and SACT naïve (table). OS MVA in CC0-1 and SACT naïve showed Oxaliplatin HIPEC was comparable to MMC HR: 0.85, 95% CI (0.60-1.19) p=0.3, HR: 0.83, 95% CI (0.51-1.35) p=0.5, respectively. Oxaliplatin HIPEC had a significant benefit on local RFS in CC0-1 (MMC vs Oxaliplatin RFS 9 vs 12 months p=0.01; distant RFS 10 vs 12 months p=0.5, local and distant RFS 6 vs 8 months p=0.3). Local RFS MVA showed a HR: 0.64, 95% CI (0.41-0.99), p=0.04 for Oxaliplatin HIPEC when corrected by PCI, N stage and grade. Conclusions: The study shows a trend to better OS with Oxaliplatin HIPEC in selected patients with low volume CRPM not requiring SACT. CRS with Oxaliplatin HIPEC is beneficial in local RFS, suggesting there is a role for local control in CRPM with Oxaliplatin HIPEC. This needs to be further explored in clinical trials. [Table: see text]

Effectiveness and Safety of CT-Guided Facet Joint Cyst Rupture for Radicular Pain as First Choice Therapy: A Retrospective Analysis

OBJECTIVE

To evaluate effectiveness and safety of computed tomography (CT)-guided cyst rupture with intraarticular contrast-enhanced injection of steroid and local anesthetic as first choice therapy in patients with facet joint cyst-induced radicular pain.

DESIGN

Retrospective data set analysis.

SETTING

University hospital.

SUBJECTS

One hundred and twenty-one patients suffering from radicular pain attributable to facet joint cysts were included.

METHODS

The rate of patients without following surgery was assessed and defined as surrogate to measure effectiveness. Patients' characteristics, procedure-associated complications, technical aspects, and imaging findings on magnetic resonance imaging (MRI) were analyzed. A subgroup of 65 patients (54%) underwent telephone interview to assess pain relief and clinical outcome measured by Numeric Rating Scale and Oswestry Disability Index. Analyses between the groups with and without surgery were performed by Fisher exact test and two-sample unpaired t-test, respectively.

RESULTS

The effectiveness of CT-guided cyst rupture was found to be 66.1%. Procedure-induced pain yielded in premature abort in two cases (1.7%). The detection of epidural contrast agent was statistically significantly associated with no need for surgery (P = .010). The cyst level was associated with the status of following surgery (P = .026), that is, cysts at lower lumbar spine were easier to rupture than cysts at other locations (cervical, thoracic, or upper lumbar spine). No further significant association was found.

CONCLUSIONS

CT-guided cyst rupture as the first-choice therapy in patients with cyst-induced radicular pain was safe and effective. Successful cyst rupture was associated with no need for surgery. Cysts at lower lumbar spine revealed the highest success rate.

FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty

Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.

Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry-Endovascular Treatment

BACKGROUND AND PURPOSE

Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice.

METHODS

Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0-2).

RESULTS

Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of time between symptom onset and reperfusion seemed to be small.

CONCLUSIONS

Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact.

Association of Quality and Technology With Patient Mobility for Colorectal Cancer Surgery

Importance

Many health care systems publish hospital-level quality measures as a driver of hospital performance and to support patient choice, but it is not known if patients with cancer respond to them.

Objective

To investigate hospital quality and patient factors associated with treatment location.

Design, Setting, and Participants

This choice modeling study used national administrative hospital data. Patients with colon and rectal cancer treated in all 163 English National Health Service (NHS) hospitals delivering colorectal cancer surgery between April 2016 and March 2019 were included. The extent to which patients chose to bypass their nearest surgery center was investigated, and conditional logistic regression was used to estimate the association of additional travel time, hospital quality measures, and patient characteristics with treatment location.

Exposures

Additional travel time in minutes, hospital characteristics, and patient characteristics: age, sex, cancer T stage, socioeconomic status, comorbidity, and rural or urban residence.

Main Outcomes and Measures

Treatment location.

Results

Overall, 44 299 patients were included in the final cohort (mean [SD] age, 68.9 [11.6] years; 18 829 [42.5%] female). A total of 8550 of 31 258 patients with colon cancer (27.4%) and 3933 of 13 041 patients with rectal cancer (30.2%) bypassed their nearest surgical center. Travel time was strongly associated with treatment location. The association was less strong for younger, more affluent patients and those from rural areas. For rectal cancer, patients were more likely to travel to a hospital designated as a specialist colorectal cancer surgery center (odds ratio, 1.45; 95% CI, 1.13-1.87; P = .004) and to a hospital performing robotic surgery for rectal cancer (odds ratio, 1.43; 95% CI, 1.11-1.86; P = .007). Patients were less likely to travel to hospitals deemed to have inadequate care by the national quality regulator (odds ratio, 0.70; 95% CI, 0.50-0.97; P = .03). Patients were not more likely to travel to hospitals with better 2-year bowel cancer mortality outcomes.

Conclusions and Relevance

Patients appear responsive to hospital characteristics that reflect overall hospital quality and the availability of robotic surgery but not to specific disease-related outcome measures. Policies allowing patients to choose where they have colorectal cancer surgery may not result in better outcomes but could drive inequities in the health care system.

Side matters: differences in functional outcome and quality of life after thrombectomy in left and right hemispheric stroke

BACKGROUND

Patients with a left (LHS) or right hemispheric stroke (RHS) differ in terms of clinical symptoms due to lateralization of specific cortical functions. Studies on functional outcome after stroke and endovascular thrombectomy (EVT) comparing both hemispheres showed conflicting results so far. The impact of stroke laterality on patient-reported health-related quality of life (HRQoL) after EVT has not yet been adequately addressed and still remains unclear.

METHODS

Consecutive stroke thrombectomy patients, derived from a multi-center, prospective registry (German Stroke Registry) between June 2015 and December 2019, were included in this study. At 90 days, outcome after EVT was assessed by the modified Rankin scale (mRS) and HRQoL using the European QoL-five dimensions questionnaire utility-index (EQ-5D-I; higher values indicate better HRQoL) in patients with LHS and RHS. Adjusted regression analysis was applied to evaluate the influence of stroke laterality on outcome after EVT.

RESULTS

In total, 5683 patients were analyzed. Of these, 2953 patients (52.8%) had LHS and 2637 (47.2%) RHS. LHS patients had a higher baseline NIHSS (16 vs. 13, p < 0.001) and a higher ASPECTS (9 vs. 8, p < 0.001) compared to RHS patients. Among survivors, patients with LHS less frequently had a self-reported affected mobility (p = 0.037), suffered less often from pain (p = 0.04) and anxiety/depression (p = 0.032) three months after EVT. After adjusting for confounders (age, sex, baseline NIHSS), LHS was associated with a better HRQoL (ß coefficient 0.04, CI 95% 0.017-0.063; p = 0.001), and better functional outcome assessed by lower values on the mRS (ß coefficient - 0.109, CI 95% - 0.217-0.000; p = 0.049).

CONCLUSIONS

Ninety days after EVT, LHS patients have a better functional outcome and HRQoL. Patients with RHS should be actively assessed and treated for pain, anxiety and depression to improve their HRQoL after EVT.

De-escalated Neoadjuvant Chemotherapy in Early Triple-Negative Breast Cancer (TNBC): Impact of Molecular Markers and Final Survival Analysis of the WSG-ADAPT-TN Trial

PURPOSE

Although optimal treatment in early triple-negative breast cancer (TNBC) remains unclear, de-escalated chemotherapy appears to be an option in selected patients within this aggressive subtype. Previous studies have identified several pro-immune factors as prognostic markers in TNBC, but their predictive impact regarding different chemotherapy strategies is still controversial.

EXPERIMENTAL DESIGN

ADAPT-TN is a randomized neoadjuvant multicenter phase II trial in early patients with TNBC (n = 336) who were randomized to 12 weeks of nab-paclitaxel 125 mg/m2 + gemcitabine or carboplatin d 1,8 q3w. Omission of further (neo-) adjuvant chemotherapy was allowed only in patients with pathological complete response [pCR, primary endpoint (ypT0/is, ypN0)]. Secondary invasive/distant disease-free and overall survival (i/dDFS, OS) and translational research objectives included quantification of a predictive impact of markers regarding selection for chemotherapy de-escalation, measured by gene expression of 119 genes (including PAM50 subtype) by nCounter platform and stromal tumor-infiltrating lymphocytes (sTIL).

RESULTS

After 60 months of median follow-up, 12-week-pCR was favorably associated (HR, 0.24; P = 0.001) with 5y-iDFS of 90.6% versus 62.8%. No survival advantage of carboplatin use was observed, despite a higher pCR rate [HR, 1.04; 95% confidence interval (CI), 0.68-1.59]. Additional anthracycline-containing chemotherapy was not associated with a significant iDFS advantage in pCR patients (HR, 1.29; 95% CI, 0.41-4.02). Beyond pCR rate, nodal status and high sTILs were independently associated with better iDFS, dDFS, and OS by multivariable analysis.

CONCLUSIONS

Short de-escalated neoadjuvant taxane/platinum-based combination therapy appears to be a promising strategy in early TNBC for using pCR rate as an early decision point for further therapy (de-) escalation together with node-negative status and high sTILs. See related commentary by Sharma, p. 4840.

First dorsal interosseous muscle transfer to restore opposition of the new thumb after index pollicization: anatomical description of an original technique and case report

Index pollicization in severe thumb hypoplasia or aplasia in children or for the reconstruction of a mutilated thumb in adults is a rare and technically demanding procedure. Weakness of the new thumb is routinely reported after index pollicization. An inappropriate position of the first dorsal interosseous muscle (FDIM) can partly explain this strength deficit. Here, we report an original anatomical study on FDIM transfer for reanimation of the new thumb's opposition function and its clinical application. An anatomical study was carried out on three upper limbs from fresh, non-embalmed adult cadavers. We demonstrated the feasibility of an FDIM transfer pedicled on the proper FDIM artery and the deep branch of the ulnar nerve. The proximal FDIM insertions were sutured to the lateral border of the flexor retinaculum to recreate the superficial thenar musculature. This procedure was performed on a 52-year-old man who was referred to us with swelling on his hand. We discovered a myxoid inflammatory fibroblastic sarcoma of the thumb that required proximal thumb amputation while preserving the base of the first metacarpal. To our knowledge, this is the first description of FDIM pedicled flap transfer during an index pollicization procedure among an adult population. However, in severe thumb hypoplasia or aplasia cases, this procedure is limited by the size and anatomical variations of the neurovascular structures among a population affected by radial longitudinal deficiency.

Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation

Background

Oral anticoagulation (OAC) is the mainstay of secondary prevention in ischemic stroke patients with atrial fibrillation (AF). However, in AF patients with large vessel occlusion stroke treated by endovascular therapy (ET) and acute carotid artery stenting (CAS), the optimal antithrombotic medication remains unclear.

Methods

This is a subgroup analysis of the German Stroke Registry—Endovascular Treatment (GSR-ET), a prospective multicenter cohort of patients with large vessel occlusion stroke undergoing ET. Patients with AF and CAS during ET were included. We analyzed baseline and periprocedural characteristics, antithrombotic strategies and functional outcome at 90 days.

Results

Among 6635 patients in the registry, a total of 82 patients (1.2%, age 77.9 ± 8.0 years, 39% female) with AF and extracranial CAS during ET were included. Antithrombotic medication at admission, during ET, postprocedural and at discharge was highly variable and overall mortality in hospital (21%) and at 90 days (39%) was high.

Among discharged patients (n = 65), most frequent antithrombotic regimes were dual antiplatelet therapy (DAPT, 37%), single APT + OAC (25%) and DAPT + OAC (20%). Comparing DAPT to single or dual APT + OAC, clinical characteristics at discharge were similar (median NIHSS 7.5 [interquartile range, 3–10.5] vs 7 [4–11], p = 0.73, mRS 4 [IQR 3–4] vs. 4 [IQR 3–5], p = 0.79), but 90-day mortality was higher without OAC (32 vs 4%, p = 0.02).

Conclusions

In AF patients who underwent ET and CAS, 90-day mortality was higher in patients not receiving OAC.

Registration: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-022-00207-7.

Impact of stromal tumor-infiltrating lymphocytes (sTILs) on response to neoadjuvant chemotherapy in triple-negative early breast cancer in the WSG-ADAPT TN trial

BACKGROUND

Higher density of stromal tumor-infiltrating lymphocytes (sTILs) at baseline has been associated with increased rates of pathological complete response (pCR) after neoadjuvant chemotherapy (NACT) in triple-negative breast cancer (TNBC). While evidence supports favorable association of pCR with survival in TNBC, an independent impact of sTILs (after adjustment for pCR) on survival is not yet established. Moreover, the impact of sTIL dynamics during NACT on pCR and survival in TNBC is unknown.

METHODS

The randomized WSG-ADAPT TN phase II trial compared efficacy of 12-week nab-paclitaxel with gemcitabine versus carboplatin. This preplanned translational analysis assessed impacts of sTIL measurements at baseline (sTIL-0) and after 3 weeks of chemotherapy (sTIL-3) on pCR and invasive disease-free survival (iDFS). Predictive performance of sTIL-0 and sTIL-3 for pCR was quantified by ROC analysis and logistic regression; Kaplan-Meier estimation and Cox regression (with mediation analysis) were used to determine their impact on iDFS.

RESULTS

For prediction of pCR, the AUC statistics for sTIL-0 and sTIL-3 were 0.60 and 0.63, respectively, in all patients; AUC for sTIL-3 was higher in NP/G. The positive predictive value (PPV) of "lymphocyte-predominant" status (sTIL-0 ≥ 60%) at baseline was 59.3%, though only 13.0% of patients had this status. To predict non-pCR, the cut point sTIL-0 ≤ 10% yielded PPV = 69.5% while addressing 33.8% of patients. Higher sTIL levels (particularly at 3 weeks) were independently and favorably associated with better iDFS, even after adjusting for pCR. For example, the adjusted hazard ratio for 3-week sTILs ≥ 60% (vs. < 60%) was 0.48 [0.23-0.99]. Low cellularity in 3-week biopsies was the strongest individual predictor for pCR (in both therapy arms), but not for iDFS.

CONCLUSION

The independent impact of sTILs on iDFS suggests that favorable immune response can influence key tumor biological processes for long-term survival. The results suggest that the reliability of pCR following neoadjuvant therapy as a surrogate for survival could vary among subgroups in TNBC defined by immune response or other factors. Dynamic measurements of sTILs under NACT could support immune response-guided patient selection for individualized therapy approaches for both very low levels (more effective therapies) and very high levels (de-escalation concepts).

TRIAL REGISTRATION

Clinical trials No: NCT01815242, retrospectively registered January 25, 2013.

Neoadjuvant durvalumab improves survival in early triple-negative breast cancer independent of pathological complete response

BACKGROUND

Addition of immune checkpoint inhibitors (CPI) to neoadjuvant chemotherapy (NACT) is a promising strategy in early breast cancer, but the optimal duration of therapy is currently unknown. In the GeparNuevo (NCT02685059) trial, addition of durvalumab to NACT as previously reported led to a moderate increase in pCR rate by absolute 9% (p=0.287).

PATIENTS AND METHODS

Durvalumab or placebo 1.5g/placebo q4 weeks plus nab-paclitaxel 125mg/m² weekly for 12 weeks, followed by 4 cycles durvalumab/placebo plus epirubicin/cyclophosphamide (EC) q2 weeks was given to cT1b-cT4a-d TNBC patients. Durvalumab was not continued after surgery. Primary objective was pathological complete response (pCR). Secondary endpoints included invasive disease-free survival (iDFS), distant disease-free survival (DDFS) and overall survival (OS).

RESULTS

174 patients were randomised between June 2016 and October 2017. After a median follow-up of 43.7 months, 34 events had occurred. Despite a non-significant increase in the pCR rate, significant differences were observed for 3-year iDFS, DDFS and OS: iDFS was 85.6% with durvalumab vs 77.2% with placebo (HR 0.48, 95%CI 0.24-0.97, stratified log-rank p=0.036); DDFS 91.7% vs 78.4% (HR 0.31, 95%CI 0.13-0.74, p=0.005); OS 95.2% vs 83.5% (HR 0.24, 95%CI 0.08-0.72, p=0.006). pCR patients had 3-year iDFS of 95.5% with durvalumab and 86.1% without (HR 0.22, 95% CI 0.05-1.06). In non-pCR cohort 3-year iDFS was 76.3% vs 69.7% (HR 0.67, 95% CI 0.29-1.54). Multivariable analysis confirmed durvalumab effect independent of the pCR effect. No new safety signals occurred.

CONCLUSION

Durvalumab added to NACT in TNBC significantly improved survival despite a modest pCR increase and no adjuvant component of durvalumab. Additional studies are needed to clarify the optimal duration and sequence of CPIs in the treatment of early TNBC.

POS1254 RISK FACTORS FOR SEVERE COVID-19 INFECTION AMONG PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES (AIRD) AND THE IMPACT OF VACCINATIONS - AN ISRAELI, MULTI-CENTER EXPERIENCE

Background

AIRD patients (pts) may be more susceptible to severe COVID19.

Objectives

To determine the risk factors for severe COVID19 and the effect of vaccinations among AIRD pts followed at dedicated rheumatology clinics.

Methods

At the onset of the pandemic, we established a national registry of AIRD pts, diagnosed with COVID19, based on voluntary reporting by the treating rheumatologist. 12 centers from Israel participated in the study. COVID19 was confirmed by a positive SARS CoV2 PCR. The indications for PCR testing were clinical symptoms or close contact with an infected person. Severe illness was defined by SpO2 <94% in room air, respiratory rate of >30 breaths/min, PaO2/FiO2 <300 mm Hg, or lung infiltrates >50% on imaging. The registry included demographic data, AIRD diagnosis and duration, visceral involvement, co-morbidities, immunomodulatory treatment, date of diagnosis and severity of COVID19 disease, management, complications, duration of hospitalization, the dates of the mRNA vaccinations, lab results and outcome. We analyzed data from 1.3.2020 to 30.11.2021

Results

During the study period we experienced 4 outbreaks of COVID19 infection. Initially social distancing, followed by a lockdown were imposed. The low number of cases led to relaxation of the measures. Two more severe outbreaks followed, which triggered 2 new lockdowns. The 3rd outbreak ended almost 2 months after vaccination started (BNT162b2 mRNA COVID19 vaccine). From March 1st 2020 to April 30, 2021, 298 AIRD pts (70.8% females, mean (SD) age 53.3(15.3)) with confirmed COVID19 infection were included. 43.3%(129) had visceral involvement due to the AIRD. 58.7%(175 pts) were on conventional synthetic disease modifying drugs (csDMARDs), 44.6% (133) on biologic/targeted DMARDs and 40% (120) on prednisone. Almost 2/3 of pts had at least one comorbidity.

In a multivariate logistic regression analysis age, AIRD with pulmonary involvement, diabetes and treatment with prednisone, mycophenolate mofetil or JAK inhibitors were associated with hospitalization. Older age, renal and vascular involvement due to the AIRD, and congestive heart failure were associated with higher mortality.

The 4th outbreak occurred 6 months after the introduction of vaccines, with spreading of the delta variant: 110 AIRD pts with COVID19 were recorded. Demographic data, clinical AIRD‘s characteristics, immunomodulatory treatment and comorbidities were similar to the previous outbreaks. However, during the 4th outbreak, the proportion of pts with severe COVID19, the hospitalization and mortality rate were significantly lower as compared to the first 3 outbreaks (15% vs 24%, 27% vs 53%, 6.7% vs 9.1%, respectively). Among COVID19 pts, 25% received a 3rd vaccine dose (booster), 56% contracted infection more than 5 months after the 2nd vaccine dose and 24% were unvaccinated. Most of the pts who received the booster contracted the disease within a week of vaccination. The odds ratio for hospitalization in vaccinated pts compared to unvaccinated was 0.11 (0.01 – 0.63 95% CI, p=0.041) in those vaccinated within the previous 1-5 months, and 0.38 (0.21-0.67 95% CI, p=0.001) in those vaccinated more than 6 months ago. 9 pts died, 5 were more than 6 months after the 2nd mRNA vaccine, 2 were unvaccinated and 1 patient received the booster on the same day of COVID19 diagnosis.

Conclusion

Before the vaccination campaign, the hospitalization and mortality rate in our cohort were similar to the data reported by other registries. COVID19 tends to be more severe, with increased mortality in patients with active AIIRD and visceral involvement (pulmonary, cardiac, renal), advanced age and co-morbidities. The delta outbreak occured 6 months after the implementation of vaccinations and was associated with significantly lower hospitalization and mortality rates, despite the increased aggressiveness of the variant. Vaccination of AIIRD pts with 3 doses of mRNA vaccines protects from severe COVID19 disease, hospitalization, and death.

Acknowledgements

Fadi Kharouf and Tali Eviatar had equal contribution

Disclosure of Interests

None declared

Biomarkers for response to immunotherapy in triple-negative breast cancer: Differences between survival and pCR biomarkers

583

Background: Immunotherapy is entering clinical practice as a promising new neoadjuvant therapeutic approach in triple-negative breast cancer, and it is important to identify biomarkers to focus this therapy on those patients that have the highest benefit. Interestingly, an improved survival outcome is observed in pCR and non-pCR patients, which raises the hypothesis that biomarkers might also be different for pCR prediction as well as prognosis. In this study, we investigated this hypothesis in the neoadjuvant GeparNuevo trial. Methods: A total of 174 patients were randomized to receive neoadjuvant chemotherapy with durvalumab vs. placebo. HTG EdgeSeq mRNA analysis was performed for a total of 2549 genes in 162 pretherapeutic core biopsies. In addition, tumor-infiltrating lymphocytes (stromal and intratumoural) as well as PD-L1 protein expression was evaluated by IHC. We systematically compared the distant disease-free survival (DDFS) of 5 predefined gene signatures (including the GeparSixto immune signature) as well as 12 single mRNA markers identified in previous projects between treatment arms using univariate Cox proportional-hazard regression analyses. In addition, exploratory biomarker analyses were performed. Results: The PSIP1 gene expression (per 1 unit hazard ratio [HR]: 0.58 95%CI 0.41-0.83; p=0.002), TAP1 (per 1 unit HR: 0.68 95%CI 0.48-0.95; p=0.025) as well as stromal TILs (sTILs) (per 10% HR: 0.73 95%CI 0.56-0.95; p=0.019) were significant for improved DDFS in the complete cohort. In the placebo arm PSIP1 (HR 0.50 95%CI 0.29-0.87; p=0.014) as well as sTILs (HR 0.73 95%CI 0.53-0.99; p=0.044) were significant for improved DDFS. In the durvalumab arm, the gene expression of PSIP1 (HR 0.54 95%CI 0.31-0.94; p=0.029), PD-L1/CD274 (per 1 unit HR: 0.41 95%CI 0.21-0.77; p=0.006), CD38 (per 1 unit: HR 0.52 95%CI 0.29-0.92; p=0.026) as well as the GeparSixto immune signature (per 1 unit HR: 0.51 95%CI 0.27-0.97; p=0.041) were significant for improved DDFS, with a positive test for interaction with treatment arm for PD-L1/CD274 (interaction p=0.020). Additional analyses, including multivariate Cox regressions for DDFS as well as systematic comparisons for biomarkers for DDFS and for pCR, will be presented. Conclusions: Our analysis suggests that biomarkers for immune response are linked to improved survival with neoadjuvant durvalumab therapy and that in this setting, survival biomarkers are not identical to pCR biomarkers. The results are a basis for a further dissection of the contribution of pCR to survival effects of immunotherapy.

Concordance and clinical impact of ER, PR, HER2 expression by local and central immunohistochemistry versus RT-PCR in HR+/HER2- early breast cancer (EBC): Results from the ADAPT trial

536

Background: We evaluated concordance of ER, PR and HER2 status between local, central, and RT-PCR/mRNA assessments and its clinical impact in the ADAPT trial collective in HR+ HER2- EBC (NCT01779206). Particularly, validity of borderline ER-positivity (expression level 1-10%) has great clinical relevance as treatment concepts between luminal-like and triple negative (TNBC) EBC differ substantially. Methods: Patients (pts) with clinically high-risk HR+/HER2- EBC (ER and/or PR >1%) were initially treated by 3 (+/-1) weeks of endocrine therapy (ET) before surgery or sequential core biopsy (CB) and then allocated to an ET-alone or chemotherapy (ET) trial, depending on risk and endocrine response. OncotypeDX (incl. RT-PCR for ER, PR, HER2) and central IHC for ER, PR, HER2 were performed on the initial 1.CB. ER-low cohort was defined as 1-10% expression by local OR central lab (ASCO-CAP). Cox models were used to estimate hazard ratios. Results: In ADAPT, 5149 pts from 81 centers in Germany with locally ER and/or PR positive (known quantitative levels) EBC were screened 2012-2018. Median follow-up was 59 months. For ER (positive vs. negative), overall concordance measured as agreement (κ) was high between all three assessments: Local vs. central IHC: 99.3% (κ = 0.45), RT-PCR vs. central IHC: 99% (κ = 0.48). Concordance was lower for PR: RT-PCR vs. central IHC: 90.5% (κ = 0.58), local vs. central IHC: 93.1% (κ = 0.56). 3% were centrally found as HER2+ in 1.CB (73% of them were negative by RT-PCR) and/or 2. Sample. Regarding HER2-low status (1+ or 2+ but ISH negative), concordance between local and central IHC was only 53.8% (κ = 0.09). Of all pts, only 2% (n=109; n=85 with both measurements available) had low ER expression (1-10%) by either local or central pathology. Only 9 of them were concordantly identified as ER-low (11%); 8/58 (14%) ER-low by local lab had TNBC by central lab. 17/47 ER-low cases (36.2%) with known post-endocrine Ki67post had Ki67post <10% vs. 59.7% in ER>10%. 41.8% of ER-low cases had RS<25 vs. 76.7% in ER>10%. All cases with ER <10% by both assessments and those with Ki-67≥40% had RS >25. We observed worse iDFS (HR 1.91, p=0.034) in the ER-low group vs. ER>10%. Conclusions: Although we have confirmed high agreement between local and central IHC and RT-PCR for ER, PR, HER2 assessment in locally HR+/HER2- EBC, there are still a few clinically relevant discordances. Regarding HER2-low status, standardization and quality assurance are needed if this becomes clinically relevant. Treatment of the heterogeneous ER-low group as TNBC appears reasonable only if “ER-low” is confirmed by a second assessment and in cases with Ki-67>40%. Preoperative ET response assessment may be helpful if an endocrine-based therapy concept is intended. Clinical trial information: NCT01779206.

POS1245 REVERSAL OF DECLINE IN HUMORAL RESPONSE TO BNT162b2 mRNA COVID-19 VACCINE AFTER BOOSTER ADMINISTRATION IN AUTOIMMUNE INFLAMMATORY RHEUMATOID DISEASES (AIRD) PATIENTS

Background

Previous studies proved that mRNA vaccinations against SARS CoV2 induced significant humoral responses in AIRD patients (pts). However, the humoral response was blunted in pts treated with CD20 depleting antibodies. There are limited data regarding the long-term outcome of the humoral response and the contribution of the booster vaccine, in immunosuppressed AIRD pts.

Objectives

To assess the long-term outcome of the humoral response to mRNA vaccine against SARS CoV2, in AIRD pts treated with immunomodulating drugs, and the contribution of the booster vaccination.

Methods

Consecutive pts treated at the Rheumatology Institute at Rambam Hospital who received their first SARS-CoV-2 (Pfizer) vaccine were recruited to the study, at their routine visit. The visit included AIRD activity assessment and questioning regarding vaccine side effects. We performed serology test 4-6 weeks and 24 weeks after receiving the second dose of vaccine. Pts who received the booster (3rd vaccine) were invited for serology tests 4-8 weeks afterwards. The immunomodulating treatment was not modified, either before or after the vaccination. IgG Antibodies (Ab) against SARS COV2 virus were detected using the SARS-Cov-2 IgG II Quant (Abbott) assay based on a chemiluminescent microparticle immunoassay (CMIA) on the ARCHITECT ci8200system from Abbott. This assay is measuring IgG antibodies against the spike receptor-binding domain (S-RBD) of the virus. The test was considered positive above 50 AU/ml.

Results

262 pts (mean age(SD) 57(13), disease duration 11.2(7.4), were recruited. The cohort included 152 pts with inflammatory joint disease, 26 pts with systemic lupus erythematosus, 62 pts with other connective tissue disease and 22 pts with vasculitis; 27 % received csDMARDs only, 35% - b/tsDMARDs only, 30% - combined therapy (csDMARDs+b/tsDMARDs) and 26% received steroids. 225 pts (86%) were seropositive for IgG Ab against SARS CoV2 virus (median 2832.5 AU/ml, IQR 58-29499). 37 (14%) pts had negative tests, 23 (62.2%) of them were rituximab treated.

The IgG levels correlated with the medication used to treat the AIRD, the patients’ age but not with the type of the AIRD (Figure 1). 24 weeks afterwards, the median IgG level dropped to 282 AU/ml and 15% of the pts with previous seropositive tests became negative. The booster administration (Pfizer) significantly augmented the humoral response (median 8328 AU/ml, IQR 375-40000). De novo serologic response was observed in 10 out of 37 pts (4/23 rituximab treated pts).

Figure 1.

The reported side effects of the vaccine were minor (muscle sore, headache, low grade fever). The AIRD remained stable in all pts following all three vaccinations.

Conclusion

Although the vast majority of AIRD pts developed a substantial humoral response following the administration of the second dose of the Pfizer mRNA vaccine against SARS CoV2 virus, the humoral response significantly declined 24 weeks afterwards. An enhanced response was obtained after the third booster vaccination. Only minor side effects were reported and no apparent impact on AIRD activity was noted. Notably, 62% of the non-responders were treated with B cell depleting agents.

Acknowledgements

We would like to thank Mrs Tsofnat Margi and Mrs Sarit Elkouby for organisational support.

Disclosure of Interests

None declared

Adjuvant dynamic marker-adjusted personalized therapy comparing endocrine therapy plus ribociclib versus chemotherapy in intermediate-risk HR+/HER2- early breast cancer: ADAPTcycle

TPS609

Background: The WSG ADAPT trial program focusses on individualization of (neo)-adjuvant decision-making in EBC in a subtype-specific manner. Clinical feasibility of the WSG ADAPT trial goals - early response assessment and subtype-specific therapy tailoring to those patients (pts) who are most likely to benefit - has recently been confirmed by the 5-years survival data of the ADAPT HR+/HER2- clinical trial. Methods: WSG-ADAPTcycle is a prospective, multi-center, interventional, two-arm, (neo)adjuvant, non-blinded, randomized, controlled phase III trial (NCT04055493) investigating whether treatment with the CDK4/6 inhibitor ribociclib (600mg/day) together with ET is superior to standard-chemotherapy (CT) in intermediate-risk HR+/HER2- EBC. Definition of intermediate-risk is either based on Oncotype DX and endocrine responder status (measured by Ki67-response after 2-4 weeks of induction endocrine therapy (ET)) or on low-intermediate baseline Ki67 and high estrogen receptor (ER)/progesterone receptor (PR)-expression (Dowsett et al. NPJ Breast Cancer 2020). Co-primary endpoints are DFS and dDFS. It is planned to screen 5600 pts and to randomize 1670 pts (1002 to ribociclib + ET; 668 to standard CT followed by ET). Study start was in July 2019 (88 sites, enrollment period 42 months) and until date of submission, 3079 pts have been screened and 811 randomized (490 ribociclib / 321 CT). Pre-/postmenopausal pts with histologically confirmed invasive HR+/HER2- EBC with high clinical risk (cT2-4 or Ki-67 20% or G3 or cN+) are eligible if they fulfil the ADAPT intermediate-risk criteria: Recurrence Score (RS) ≤25 plus several risk factors and poor ET responder, RS >25 and ET-responder in p/cN0-1 pts, or RS ≤25 with c/pN2-3 in ET-responder. Direct randomization of premenopausal patients (irrespective of ET-response) with c/pN0 and RS 16-25 or c/pN1 with RS 0-25 is allowed according to investigator´s decision; however, based on the ADAPT results, ET+ovarian function suppression alone is strongly recommended in ET-responders. Treatment duration is 2 years for the ribociclib + aromatase inhibitor (AI) (premenopausal: AI + GnRH)-arm and 16-24 weeks for the CT-arm; neoadjuvant or adjuvant treatment is allowed. The minimum 5-year follow-up phase includes standard adjuvant ET. ePROs are collected using CANKADO; ECG monitoring is performed using a novel eHealth method. Translational analyses: Tumor tissue will be collected prior to ET, after at least 3 weeks of ET, if residual tumor is diagnosed (neoadjuvant treatment), and at recurrence, to identify potential resistance markers. Exploratory tissue biomarker research will be conducted to assess alterations in molecular markers. In addition, ctDNA/ctRNA from optional blood samples will be assessed for mutations and gene expression relevant for HR+/HER2- EBC. Clinical trial information: NCT04055493.

Deep learning-based classification of DSA image sequences of patients with acute ischemic stroke

PURPOSE

Recently, a large number of patients with acute ischemic stroke benefited from the use of thrombectomy, a minimally invasive intervention technique for mechanically removing thrombi from the cerebrovasculature. During thrombectomy, 2D digital subtraction angiography (DSA) image sequences are acquired simultaneously from the posterior-anterior and the lateral view to control whether thrombus removal was successful, and to possibly detect newly occluded areas caused by thrombus fragments split from the main thrombus. However, such new occlusions, which would be treatable by thrombectomy, may be overlooked during the intervention. To prevent this, we developed a deep learning-based approach to automatic classification of DSA sequences into thrombus-free and non-thrombus-free sequences.

METHODS

We performed a retrospective study based on the single-center DSA data of thrombectomy patients. For classifying the DSA sequences, we applied Long Short-Term Memory or Gated Recurrent Unit networks and combined them with different Convolutional Neural Networks used as feature extractor. These network variants were trained on the DSA data by using five-fold cross-validation. The classification performance was determined on a test data set with respect to the Matthews correlation coefficient (MCC) and the area under the curve (AUC). Finally, we evaluated our models on patient cases, in which overlooking thrombi during thrombectomy had happened.

RESULTS

Depending on the specific model configuration used, we obtained a performance of up to 0.77[Formula: see text]0.94 for the MCC[Formula: see text]AUC, respectively. Additionally, overlooking thrombi could have been prevented in the reported patient cases, as our models would have classified the corresponding DSA sequences correctly.

CONCLUSION

Our deep learning-based approach to thrombus identification in DSA sequences yielded high accuracy on our single-center test data set. External validation is now required to investigate the generalizability of our method. As demonstrated, using this new approach may help reduce the incident risk of overlooking thrombi during thrombectomy in the future.

Fifty-fifty - a comparison of two 50 watts high power short duration protocols using temperature- versus power- controlled radiofrequency ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Radiofrequency-guided catheter ablation (RFCA) is an established treatment option for atrial fibrillation (AF). New approaches applying higher than usual energy levels for shorter periods (high power short duration, HPSD) to improve lesion quality have been reported. The novel DiamondTemp (DT) catheter allows for temperature-guided high power RFCA. Data on a direct comparison of the two emerging RFCA approaches are lacking.

Purpose

This observational single center study aimed to compare the efficacy, safety and characteristics of the novel DT catheter to an ablation index (AI) guided 50 W high power short duration (HPSD) ablation protocol using a conventional force-sensing equipped ablation catheter with surround-flow.

Methods

A total number of 101 patients undergoing RFA for AF were included. 33 patients treated with the DT catheter (50 W, 9 sec), were compared to 69 consecutive patients undergoing AI-guided AF ablation (AI anterior 550; AI posterior 400) with an open-irrigated catheter adherent to a 50 W HPSD protocol. Procedural data and recurrence rates were documented. Follow-up examinations were scheduled after 3, 6 and 12 months.

Results

Acute procedural success was achieved in all patients (n=101, 100%). DT-guided AF ablation was associated with a significantly longer mean procedure duration (98.8±30.1min vs. 78.2±25.6, p=0.002*). PVI using the DT ablation catheter required significantly more RF applications (75.4±30.8min vs. 61.3±14.1, p=0.019*). Total RF duration was significantly lower in the DT group (792.1±311.2sec vs. 1035.5±287.2sec, p&lt;0.001*) as well as fluoroscopy time (4.6±2.1min vs.5.5±2.5min, p&lt;0.006*) and dose (183.8±178.1yGym2 vs. 295.8±247.5yGym2, p&lt;0.013*). Procedure related mayor complications occurred in 1 patient from the DT group (acute stroke; 3%) and in no patients from the HPSD cohort. Early recurrence was reported from 4 patients treated with the DT catheter (12%) compared to 8 patients undergoing HPSD RFA (12 %) (p=1.000).

Conclusion

Temperature- and power- controlled AF ablation using 50 W was safe and effective. AI-guided HPSD ablation resulted in significantly shorter procedure times with significantly fewer RF applications for PVI, whereas total RF duration and fluoroscopy times were significantly higher in this cohort. Further studies are needed to confirm this initial observation.

The novel POLARx ablation system improves cryothermal single-shot guided pulmonary vein isolation: impact of individual pulmonary vein anatomy

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). Recently, a novel balloon-guided cryothermal single shot device (POLARx) was introduced.

Purpose

This observational study aimed to evaluate ablation efficacy and outcome using the novel POLARx CB system compared to the established one and to access the impact of individual PV characteristics on freedom from arrhythmia recurrence in paroxysmal (PAF) and persistent (PERS) AF.

Methods

666 patients undergoing CB-guided ablation for AF were included. 601 patients treated with the AFA ablation system (Arctic Front Advance Pro, AFA) were compared to 65 consecutive patients who underwent PVI using the POLARx. Individual anatomical characteristics of the left atrium and PVs were assessed using pre-procedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional orifice area (CSOA) was determined. Follow-up examinations were scheduled after 3 and 6 months.

Results

Acute PVI was achieved in all patients (100%). 6-months AF-free survival was significantly higher in the POLARx cohort (POLARx: n=45, 69%; AFA: n=359, 60%; Log-rank p=0.037*). This applies to PAF (n=42, 65%, p=0.033*), PERS (n=23, 35%, p&lt;0.001*) and normal PV anatomy (2 left- and two right-sided PVs; n=57, 88%, p&lt; 0.001*). MRI found a comparable percentage of patients with normal PV anatomy (POLARx: n=57, 88%; AFA: n=512, 85%, p=0.126). A higher amount of variant PV anatomy was revealed in patients with PERS AF (p=0.043*), but this factor was not predictive for AF-recurrence (PAF: p=0.610; PERS: p=0.096). PAF patients with AF-recurrence presented with significantly larger CSOA of the left sided PVs and the right superior PVs (LSPV: 224.8 ± 98.1 mm2 vs. 220.6 ± 64.8 mm2, p&lt;0.001*; LIPV: 145.9 ± 63.2 mm2 vs. 140.4 ± 52.8 mm2, p&lt;0.001*; RSPV 268.9 ± 79.3 mm2 vs. 262.3 ± 75.6 mm2, p&lt;0.001*). In patients with PERS AF no association between CSOA and ablation outcome was observed. Multivariate Cox regression analyses identified the AFA ablation system (p=0.022*, hazard ratio (HR) 1.776, confidence interval (CI) 0.240-9.281) and PERS AF (p&lt;0.001*, HR 6.608, CI 0.220-73.839) as independent predictors for AF-recurrence.

Conclusion

PVI using the POLARx system improves freedom from AF recurrence independent of individual anatomical considerations and PV occlusion rates. For PAF patients, a significant association between CSOA and the outcome after CB- guided PVI was demonstrated.

Endocrine Therapy Response and 21-Gene Expression Assay for Therapy Guidance in HR+/HER2- Early Breast Cancer

PURPOSE

To our knowledge, WSG-ADAPT-HR+/HER2- (NCT01779206; n = 5,625 registered) is the first trial combining the 21-gene expression assay (recurrence score [RS]) and response to 3-week preoperative endocrine therapy (ET) to guide systemic therapy in early breast cancer.

MATERIALS AND METHODS

Baseline and postendocrine Ki67 (Ki67_post) were evaluated centrally. In the endocrine trial, all patients received exclusively ET: patients with pathologic regional lymph node status (pN) 0-1 (ie, 0-3 involved lymph nodes) entered control arm if RS ≤ 11 and experimental arm if RS12-25 with ET response (Ki67_post ≤ 10%). All other patients (including N0-1 RS12-25 without ET response) received dose-dense chemotherapy (CT) followed by ET in the CT trial. Primary end point of the endocrine trial was noninferiority of 5-year invasive disease-free survival (5y-iDFS) in experimental (v control) arm; secondary end points included distant DFS, overall survival, and translational research.

RESULTS

Intention-to-treat population comprised 2,290 patients (n = 1,422 experimental v n = 868 control): 26.3% versus 34.6% premenopausal and 27.4% versus 24.0% pN1. One-sided 95% lower confidence limit of the 5y-iDFS difference was -3.3%, establishing prespecified noninferiority (P = .05). 5y-iDFS was 92.6% (95% CI, 90.8 to 94.0) in experimental versus 93.9% (95% CI, 91.8 to 95.4) in control arm; 5-year distant DFS was 95.6% versus 96.3%, and 5-year overall survival 97.3% versus 98.0%, respectively. Differences were similar in age and nodal subgroups. In N0-1 RS12-25, outcome of ET responders (ET alone) was comparable with that of ET nonresponders (CT) for age > 50 years and superior for age ≤ 50 years. ET response was more likely with aromatase inhibitors (mostly postmenopausal) than with tamoxifen (mostly premenopausal): 78.1% versus 41.1% (P < .001). ET response was 78.8% in RS0-11, 62.2% in RS12-25, and 32.7% in RS > 25 (n = 4,203, P < .001).

CONCLUSION

WSG-ADAPT-HR+/HER2- demonstrates that guiding systemic treatment by both RS and ET response is feasible in clinical routine and spares CT in pre- and postmenopausal patients with ≤ 3 involved lymph nodes.

Redox Replacement of Silver on MOF-Derived Cu/C Nanoparticles on Gas Diffusion Electrodes for Electrocatalytic CO2 Reduction

Bimetallic tandem catalysts have emerged as a promising strategy to locally increase the CO flux during electrochemical CO₂ reduction, so as to maximize the rate of conversion to C-C-coupled products. Considering this, a novel Cu/C-Ag nanostructured catalyst has been prepared by a redox replacement process, in which the ratio of the two metals can be tuned by the replacement time. An optimum Cu/Ag composition with similarly sized particles showed the highest CO₂ conversion to C₂₊ products compared to non-Ag-modified gas-diffusion electrodes. Gas chromatography and in-situ Raman measurements in a CO₂ gas diffusion cell suggest the formation of top-bound linear adsorbed *CO followed by consumption of CO in the successive cascade steps, as evidenced by the increasingνC-H bands. These findings suggest that two mechanisms operate simultaneously towards the production of HCO₂ H and C-C-coupled products on the Cu/Ag bimetallic surface.

Adverse Events and Complications in Continuous Intra-arterial Nimodipine Infusion Therapy After Aneurysmal Subarachnoid Hemorrhage

Objective

To determine the frequency and severity of complications associated with the continuous intra-arterial infusion of nimodipine (CIANI) as a new treatment of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH).

Methods

Patients from two centers (n = 718) treated for SAH between 2008 and 2016 were included. Demographic and SAH-related parameters were evaluated, and also the frequency of adverse events (AEs) and complications including their severity (mild, moderate, and severe). Clinical outcome was analyzed using Glasgow Outcome Scale (GOS). The unfavorable outcome was defined as GOS 1 to 3, and favorable outcome as GOS 4 to 5. The Short-Form 36 (SF-36) health-related quality-of-life (QoL) questionnaire served as a QoL measurement.

Results

Of 718 patients, 65 (9%) were treated by CIANI and had a higher clinical or imaging grade of bleeding severity. Clinical deterioration while on treatment happened more often in patients who were treated with CIANI than in others. In patients with CIANI, 67% had AEs and/or complications during the treatment. Nimodipine-associated hypotension was seen in 8% (mild). Catheter-associated thrombus occurred in 9% (moderate). New intracerebral hemorrhage was found in 14% (moderate). A total of 6% treated by CIANI died during the treatment period (severe). More than one-third (39%) of patients of CIANI reached at least moderate disability, and 23% showed good recovery. Patients who received CIANI showed reduced QoL, but differences in mental and general health, and also pain were minimal.

Conclusion

Patients who received CIANI had higher rates of AEs and complications. However, this does not exclude the possibility that the use of CIANI might be helpful in patients with severe and therapy-refractory CV and DCI. Controlled and randomized studies would be helpful to clarify this question but they are methodologically and ethically challenging.

Abstract PD10-11: Keyriched-1- A prospective, multicenter, open label, neoadjuvant phase ii single arm study with pembrolizumab in combination with dual anti-HER2 blockade with trastuzumab and pertuzumab in early breast cancer patients with molecular HER2-enriched intrinsic subtype

Background: De-escalating strategies seem promising in HER2-positive early breast cancer (EBC) and chemo-free regimens are thus of key interest. Recent data have underlined the role of tumor immunogenicity in response to de-escalated neoadjuvant anti-HER2 therapy. Therefore, the prospective single arm hypothesis-generating phase II KEYRICHED-1 trial (NCT03988036) investigates the pCR-rate in patients with HER2-enriched EBC receiving four cycles of the dual anti-HER2 blockade in combination with the checkpoint inhibitor pembrolizumab. Initial studies with dual antibody-based HER2 blockade alone were able to achieve pCR-rates of 20-40%, which did not quite match the pCR-rates obtained with concurrent chemotherapy. KEYRICHED-1 aims at achieving pCR-rates comparable to standard chemotherapy-containing regimens by incorporating appropriate molecular selection and immune oncology.. Methods: A total of 48 pre- and postmenopausal patients with newly diagnosed HER2 2+ or 3+ EBC (stage I-III) and HER2-enriched (HER2-E) subtype by PAM50 were enrolled in this single-arm study. All patients received four cycles of study treatment with pembrolizumab (200mg), trastuzumab biosimilar (Trazimera®, loading dose 8mg/kg bodyweight (BW), maintenance dose 6mg/kg BW), and pertuzumab (loading dose 840mg/kg BW, maintenance dose 420mg/kg BW) q21d. Primary endpoint was centrally confirmed pCR (ypT0/is, ypN0). The trial was planned as a Simon's two-stage design (null and alternative pCR were 40% and 60%); interim analysis after 16 patients had to show a pCR rate of at least 50% to continue recruitment.. Results: Between 05/2020 and 03/2021, 98 patients were screened. N=52 (55%) had HER2-E subtype, of whom 48 patients entered the treatment phase. Median patient age was 57 years (28-83). 65% had tumors &gt; 2 cm and 30% positive lymph node status. Centrally confirmed pCR-rate in surgical specimens was 46% (95% CI 0.31-0.62) in the 43 patients of the per-protocol-population, and 52% (95%CI 0.37-0.67) in all 46 evaluable patients (local assessment; two pCRs verified only by core biopsy) (p=0.22 and p=0.06 for null hypothesis, respectively). Despite HER2-E subtype, no pCR was observed in the four patients with immunohistochemical (IHC) HER2 2+/ISH-positive status in contrast to 20/39 (51.2%) pCR in IHC HER2 3+ tumors. Centrally confirmed pCR-rate in HR+/HER2+ tumors was 38.5% compared to 58.5% in HR-/HER2+ tumors. No new safety signals were observed.. Conclusions: These are the first results of a neoadjuvant chemotherapy-free 12-week de-escalation anti-HER2-regimen with trastuzumab and pertuzumab in combination with the PD-1 inhibitor pembrolizumab in patients with a HER2-E EBC. In the context of the WSG ADAPT HER2+ de-escalation trials the observed pCR-rates compare favorably in HR+ as well as HR- HER2+ EBC. Moreover, KEYRICHED-1 demonstrates that with appropriate molecular patient selection clinically meaningful pCR-rates in the range of those obtained with longer, more toxic chemotherapy-containing regimens can be achieved.

Citation Format: Sherko Kuemmel, Oleg Gluz, Mattea Reinisch, Athina Kostara, Iris Scheffen, Monika Graeser, Rachel Wuerstlein, Ulrike Nitz, Kerstin Luedtke-Heckenkamp, Andreas Hartkopf, Felix Hilpert, Angela Kentsch, Carsten Ziske, Reinhard Depenbusch, Michael Braun, Jens Blohmer, Christine zu Eulenburg, Matthias Christgen, Stephan Bartels, Hans Kreipe, Enrico Pelz, Peter Schmid, Nadia Harbeck. Keyriched-1- A prospective, multicenter, open label, neoadjuvant phase ii single arm study with pembrolizumab in combination with dual anti-HER2 blockade with trastuzumab and pertuzumab in early breast cancer patients with molecular HER2-enriched intrinsic subtype [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD10-11.

Abstract OT2-29-01: neoMono - An adaptive randomized neoadjuvant two arm trial in patients with TNBC comparing a mono atezolizumab window followed by atezolizumab and chemotherapy with atezolizumab and chemotherapy

Background: Improvement of systemic treatment of TNBC represents an unmet medical need. Recently, targeted therapy of regulatory immune pathways has become an important option in the treatment of numerous malignancies including breast cancer. Neoadjuvant trials combining chemotherapy and checkpoint inhibitors (KEYNOTE-522 and IMPASSION031) have demonstrated a meaningful benefit regarding pathological complete remission (pCR) and event-free survival (EFS) for the addition of PD-1- and PD-L1-inhibitors to chemotherapy among patients with TNBC, respectively. In addition, initial analyzes have presented promising results regarding event-free survival. In the neoadjuvant GeparNuevo trial only a subgroup of patients with TNBC, receiving a 2-week checkpoint inhibitor monotherapy window before the start of neoadjuvant chemotherapy in combination with checkpoint inhibition, achieved a pCR benefit as compared to patients treated with neoadjuvant chemotherapy alone. Trial Design: NeoMono is a phase 2 randomized multicenter trial recruiting male and female patients with primary TNBC (defined as ER/PR &lt; 10% and HER2 negative). Neoadjuvant treatment in Arm A and B consists of Atezolizumab 1200 mg every 3 weeks in addition to neoadjuvant chemotherapy (i.e. 12 x Carboplatin and Paclitaxel q1w followed by Epirubicin and Cyclophosphamide q3w) In Arm A this therapy is preceded by Atezolizumab 840 mg q2w (Atezolizumab mono window). Study goals are the comparison of efficacy and safety of neoadjuvant chemotherapy with Atezolizumab with and without Atezolizumab two-week window (primary endpoint: pCR) and the identification of biomarkers predicting (early) response to or resistance against Atezolizumab. The broad translational program of the neoMono trial aims at identifying these biomarkers on tumor and patient level. The neoMono statistical design adapts the idea of a proof-of-concept trial and uses Bayesian posterior and predictive probabilities for inference about the primary hypothesis. Up to four planned efficacy interim analyses provide decision points for early stopping for success or futility. The expected maximum number of patients to be recruited is 458.

Citation Format: Cornelia Kolberg-Liedtke, Johannes Schumacher, Ramona Erber, Michael Braun, Bernhard Heinrich, Oliver Hoffmann, Peter Fasching, Helmut Forstbauer, Anke Kleine-Tebbe, Georg Kunz, Michael Lux, Joachim Rom, Christian Schem, Nicole Stahl, Arndt Hartmann, Sabine Kasimir-Bauer, Hans-Christian Kolberg. neoMono - An adaptive randomized neoadjuvant two arm trial in patients with TNBC comparing a mono atezolizumab window followed by atezolizumab and chemotherapy with atezolizumab and chemotherapy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT2-29-01.

Abstract P2-13-03: KEYRICHED-1 - A prospective, multicenter, open label, neoadjuvant phase II single arm study with pembrolizumab in combination with dual anti-HER2 blockade with trastuzumab and pertuzumab in early breast cancer patients with molecular HER2-enriched intrinsic subtype

Background: De-escalating strategies seem promising inHER2-positive early breast cancer (EBC) and chemo-free regimens are thus of keyinterest. Recent data have underlined the role of tumor immunogenicity inresponse to de-escalated neoadjuvant anti-HER2 therapy. Therefore, theprospective single arm hypothesis-generating phase II KEYRICHED-1 trial (NCT03988036)investigates the pCR rate in patients with HER2-enriched EBC receiving fourcycles of the dual anti-HER2 blockade in combination with the checkpointinhibitor pembrolizumab. Initial studies with dual antibody-based HER2 blockadealone were able to achieve pCR-rates of 20-40%, which did not quite match the pCRrates obtained with concurrent chemotherapy. KEYRICHED-1 aims at achieving pCR-ratescomparable to standard chemotherapy-containing regimens by incorporating appropriatemolecular selection and immune oncology. Methods: A total of 48 pre- and postmenopausal patients with newly diagnosed HER22+ or 3+ EBC (stage I-III) and HER2-enriched (HER2-E) subtype by PAM50 wereenrolled in this single-arm study. All patients received four cycles of studytreatment with pembrolizumab (200mg), trastuzumab biosimilar (Trazimera®,loading dose 8mg/kg bodyweight (BW), maintenance dose 6mg/kg BW), and pertuzumab(loading dose 840mg/kg BW, maintenance dose 420mg/kg BW) q21d . Primaryendpoint was centrally confirmed pCR (ypT0/is, ypN0). The trial was planned asa Simon's two-Stage design (null and alternative pCR were 40% and 60%); interimanalysis after 16 patients had to show a pCR rate of at least 50% to continuerecruitment. Results: Between 05/2020 and 03/2021, 98 patients werescreened. N=52 (55%) had HER2-E subtype,of whom 48 patients entered thetreatment phase. Median patient age was 57 years (28-83). 65% had tumors &gt; 2cm and 30% positive lymph node status. Centrally confirmed pCR rate in surgicalspecimens was 46% (95% CI 0.31-0.62) in the 43 patients of the per protocolpopulation, and 52% (95%CI 0.37-0.67) in all 46 evaluable patients (localassessment; two pCRs verified only by core biopsy) (p=0.22 and p=0.06 for nullhypothesis, respectively). Despite HER2-E subtype, no pCR was observed in the 4patients with immunohistochemical (IHC) HER2 2+/ISH-positive status in contrastto 20/39 (51.2%) pCRs in IHC HER2 3+ tumors. Centrally confirmed pCR rate in HR+/HER2+tumors was38.5% compared to 58.5% in HR-/HER2+ tumors. No new safety signals wereobserved. Conclusions: These are the first results of a neoadjuvant chemotherapy-free12-week de-escalation anti-HER2-regimen with trastuzumab and pertuzumab incombination with the PD-1 inhibitor pembrolizumab in patients with a HER2-E EBC.In the context of the WSG ADAPT HER2+ de-escalation trials the observed pCRrates compare favourably in HR+ as well as HR- HER2 EBC. Moreover, KEYRICHED-1demonstrates that with appropriate molecular patient selection clinicallymeaningful pCR rates in the range of those obtained with longer, more toxicchemotherapy-containing regimens can be achieved.

Citation Format: Sherko Kuemmel, Oleg Gluz, Mattea Reinisch, Athina Kostara, Iris Scheffen, Monika Graeser, Kerstin Luedtke-Heckenkamp, Andreas Hartkopf, Felix Hilpert, Angela Kentsch, Carsten Ziske, Reinhard Depenbusch, Michael Braun, Jens Blohmer, Christine zu Eulenburg, Matthias Christgen, Stephan Bartels, Hans Kreipe, Enrico Pelz, Peter Schmid, Nadia Harbeck. KEYRICHED-1 - A prospective, multicenter, open label, neoadjuvant phase II single arm study with pembrolizumab in combination with dual anti-HER2 blockade with trastuzumab and pertuzumab in early breast cancer patients with molecular HER2-enriched intrinsic subtype [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-13-03.

The Value of APTw CEST MRI in Routine Clinical Assessment of Human Brain Tumor Patients at 3T

Background. With fast-growing evidence in literature for clinical applications of chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI), this prospective study aimed at applying amide proton transfer-weighted (APTw) CEST imaging in a clinical setting to assess its diagnostic potential in differentiation of intracranial tumors at 3 tesla (T). Methods. Using the asymmetry magnetization transfer ratio (MTRasym) analysis, CEST signals were quantitatively investigated in the tumor areas and in a similar sized region of the normal-appearing white matter (NAWM) on the contralateral hemisphere of 27 patients with intracranial tumors. Area under curve (AUC) analyses were used and results were compared to perfusion-weighted imaging (PWI). Results. Using APTw CEST, contrast-enhancing tumor areas showed significantly higher APTw CEST metrics than contralateral NAWM (AUC = 0.82; p < 0.01). In subgroup analyses of each tumor entity vs. NAWM, statistically significant effects were yielded for glioblastomas (AUC = 0.96; p < 0.01) and for meningiomas (AUC = 1.0; p < 0.01) but not for lymphomas as well as metastases (p > 0.05). PWI showed results comparable to APTw CEST in glioblastoma (p < 0.01). Conclusions. This prospective study confirmed the high diagnostic potential of APTw CEST imaging in a routine clinical setting to differentiate brain tumors.