BRCA1 and BRCA2 carriers with breast, ovarian and prostate cancer demonstrate a different pattern of metastatic disease compared with non-carriers: results from a rapid autopsy programme

AIM

To catalogue and compare the pattern of metastatic disease in germline BRCA1/2 pathogenic mutation carriers and non-carriers with breast, ovarian and prostate cancer from a rapid autopsy programme.

METHODS AND RESULTS

The number of metastases in the major body systems and the proportion of participants with metastases were documented in 50 participants (19 germline mutation carriers). Analysis was conducted on the participants' pattern of disease for the different cancers and mutation subgroups. The four commonly affected organ systems were the digestive (liver only) (82%), respiratory (76%), gastrointestinal (65%) and reticuloendothelial (42%). There were significant differences in the pattern of metastatic breast cancer in BRCA1/2 germline carriers compared with non-carriers. Breast cancer carriers had significantly fewer organ systems involved (median n = 3, range = 1-3) compared with non-carriers (median n = 9, range = 1-7) (P = 0.03). BRCA1/2 carriers with ovarian carcinomas had significantly more organ systems with metastatic carcinoma (median n = 10, range = 3-8) than non-carriers (median n = 5, range = 3-5) (P < 0.001). There were no significant differences in the number of involved systems in BRCA2 carriers compared with non-carriers with prostate cancer (P = 1.0). There was an absence of locoregional disease (6.5%) compared with distant disease (93.5%) among the three cancer subtypes (P < 0.001). The majority of metastatic deposits (97%) collected during the autopsy were identified by recent diagnostic imaging.

CONCLUSION

Even though a major limitation of this study is that our numbers are small, especially in the breast cancer carrier group, the metastatic patterns of breast and ovarian cancers may be impacted by BRCA1/2 carrier status, suggesting that tumours derived from patients with these mutations use different mechanisms of dissemination. The findings may focus clinical diagnostic imaging for monitoring metastases where whole-body imaging resources are scant.

1365 PROACTIVE IT-ASSISTED CGA IN CARE HOMES IMPROVES ADHERENCE TO PREFERRED PLACE OF CARE AND DEATH, HOSPITALISATION AND MORTALITY RATES

Introduction

Primary care-based frailty identification and proactive comprehensive geriatric assessment (CGA) remains challenging. Our Devon-based Primary Care Network has developed and introduced an innovative, community-based IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We wished to see if this process could improve effectiveness of ACP in residential care home (CH) residents.

Methods/Intervention

Interim analysis focused on adherence to ACP-documentation in severely frail residents, comparing groups:

Results

i-CGA group: 196 residents (16 mild/69 moderate/111 severe frailty); control group: 100(13 mild/31 moderate/56 severe). No significant baseline differences. 100% residents in the i-CGA group had documented resuscitation decisions, vs 72% (72/100) controls: in 97% of both groups (191/196,70/72) to ‘allow a natural death'. 85% (94/111) severely frail i-CGA residents preferred not to be hospitalised. 55% (52/94) died, 90% (47/52) in their CH. Compared to the preceding year, unplanned hospitalisation rates fell:0.86 to 0.68/person years alive. In severely frail control residents, unplanned hospitalisations increased: 0.87 to 2.05/person years alive. 29% (16/56) had no hospitalisation preferences documented. 16/16 died, 25% (4/16) in hospital. 40/56 had documented decisions, not all recent:38% (15/40) wished for admission. Significant group mortality difference was seen: 55% (62/111) severely frail i-CGA residents died compared to 77% (43/56) controls, p=0.0013.

Conclusions

Proactive primary care-led i-CGA in severely frail CH residents promotes up-to-date discussions regarding preferred place of care and death. Most prefer not to be hospitalised, despite traditionally high rates of unplanned admissions. Our i-CGA/ACP process improves adherence to preferences, reduces unplanned hospitalisations and mortality rates. Progressive i-CGA completion and annual/opportunistic reviews should confer progressive benefits.

New biomarkers for checkpoint inhibitor therapy

Immune checkpoint inhibitor blockade has vastly changed treatment paradigms and improved outcomes of many solid organ malignancies. The achievements of the last decade have transformed the outcomes of several tumour types, most notably metastatic melanoma. There are, however, still large numbers of patients who receive checkpoint inhibitor therapy and do not respond. In addition to potential lack of efficacy, checkpoint inhibitors also come with a unique and sometimes devastating side-effect profile. There exists a strong need for biomarkers to accurately predict response, improve treatment selection and avoid exposing patients to toxicity where there is minimal likelihood of response. There is a wide range of methodologies investigating predictive biomarkers in this space; in this review, we address the major putative biomarkers of interest. These include conventional serum tests such as lymphocyte indices and lactate dehydrogenase, and more novel research markers such as interleukin-6 and T receptor clonality. We discuss tumorous factors that may be of interest in certain tumour types, and finally gene expression profiling. Significant research continues into many of these potential predictive biomarkers in response to the emergent need to better select patients who will benefit from treatment.

Cancer outcomes in patients requiring immunosuppression in addition to corticosteroids for immune-related adverse events after immune checkpoint inhibitor therapy

AIM

To examine the cancer-specific outcomes for patients who experience immune-related adverse events requiring immunosuppression beyond corticosteroids.

METHODS

We performed a retrospective case series of patients between January 1, 2009 and April 1, 2018, across three metropolitan hospitals in Adelaide, South Australia. Eligible patients were identified from pharmacy records. Patients with a solid organ malignancy had discontinued checkpoint inhibitor therapy due to toxicity, and required immunosuppression in addition to corticosteroids to treat any immune-related adverse event.

RESULTS

From 3860 patient dispensation records of immunosuppressive medications, 19 eligible patients were identified. Eight received a CTLA-4 inhibitor, four a PD-1 inhibitor, five combination immunotherapy, and two remained blinded. Sixteen patients had melanoma and three had non-small cell lung cancer. Median time to treatment failure was 8.7 months, and median overall survival was 9.4 months. Of those evaluable, the objective response rate was 35%, while 53% had progressive disease. Four patients died due to complications of their irAE, while six died from progressive disease.

CONCLUSION

Patients who received immunosuppression for checkpoint inhibitor therapy toxicity had variable outcomes. This in part reflects a heterogeneous population, and the evolution of irAE management over time. Several patients continued to derive a benefit after cessation of therapy despite the use of immunosuppressive medications; conversely, four died as a direct consequence of their irAE. Physicians should promptly introduce immunosuppressive therapy in patients not responding to corticosteroids to mitigate the risk of life-threatening adverse events, given that current evidence does not clearly demonstrate a detriment to cancer-specific outcomes.

Video-assisted thoracoscopy in the management of intrapleural extravasation of cytotoxic chemotherapy

The extravasation of cytotoxic agents into subcutaneous tissue is a serious complication of chemotherapy. Unfortunately, if such extravasation occurs into the pleural space, limited data is available to guide appropriate management. We present the first report in the literature of video‐assisted thoracoscopy combined with a topoisomerase II inhibitor and iron chelator, dexrazoxane, in the successful management of this complication.

Difficulties with assessing the benefit of glucosamine sulphate as a treatment for osteoarthritis

Osteoarthritis is a chronic disease with a major impact on quality of life for a large proportion of the population. It is a disease for which to date there has been no disease-modifying therapy identified. As a result of its physiological role in articular cartilage, glucosamine sulphate has been postulated as a treatment for osteoarthritis. Claims have included symptomatic relief and even reduction in the rate of disease progression. Despite promising in vitro studies, however, the role of glucosamine sulphate in the management of osteoarthritis remains unclear. Studies addressing this issue have generated a wide range of conclusions, and these are discussed here. Methodological issues need to be addressed in order to gauge whether there is true benefit. On current evidence, it would appear that the benefits of dietary supplementation with glucosamine sulphate are limited to mild symptomatic relief, while a disease-modifying agent for this disease remains elusive.