Antibody-drug conjugates: Principles and opportunities

Antibody-drug conjugates (ADCs) are immunoconjugates that combine the specificity of monoclonal antibodies with a cytotoxic agent. The most appealing aspects of ADCs include their potential additive or synergistic effects of the innate backbone antibody and cytotoxic effects of the payload on tumors without the severe toxic side effects often associated with traditional chemotherapy. Recent advances in identifying new targets with tumor-specific expression, along with improved bioactive payloads and novel linkers, have significantly expanded the scope and optimism for ADCs in cancer therapeutics. In this paper, we will first provide a brief overview of antibody specificity and the structure of ADCs. Next, we will discuss the mechanisms of action and the development of resistance to ADCs. Finally, we will explore opportunities for enhancing ADC efficacy, overcoming drug resistance, and offer future perspectives on leveraging ADCs to improve the outcome of ADC therapy for cancer treatment.

Utilization and outcome disparities in allogeneic hematopoietic stem cell transplant in the United States

Allogeneic hematopoietic stem cell transplant (allo-HSCT) is increasingly being used in the United States (US) and across the world as a curative therapeutic option for patients with certain high-risk hematologic malignancies and non-malignant diseases. However, racial and ethnic disparities in utilization of the procedure and in outcome following transplant remain major problems. Racial and ethnic minority patients are consistently under-represented in the proportion of patients who undergo allo-HSCT in the US. The transplant outcomes in these patients are also inferior. The interrelated driving forces responsible for the differences in the utilization and transplant outcome of the medical intervention are socioeconomic status, complexity of the procedure, geographical barriers, and the results of differences in the genetics and comorbidities across different races. Bridging the disparity gaps is important not only to provide equity and inclusion in the utilization of this potentially life-saving procedure but also in ensuring that minority groups are well represented for research studies about allo-HSCT. This is required to determine interventions that may be more efficacious in particular racial and ethnic groups. Various strategies at the Federal, State, and Program levels have been designed to bridge the disparity gaps with varying successes. In this review paper, we will examine the disparities and discuss the strategies currently available to address the utilization and outcome gaps between patients of different races in the US.

Adjuvant Chemotherapy in Premenopausal Patients With Hormone-Positive Breast Cancer With a Recurrence Score of 16-25: A Retrospective Analysis Using the National Cancer Database

PURPOSE

Results from the TAILORx trial revealed that the use of adjuvant chemotherapy along with endocrine therapy had no survival advantage in patients with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2-negative (HER2-), node-negative (N0) breast cancer (BC) with an intermediate (11-25) 21-gene recurrence score (RS) in the overall population. However, in patients under age 50 years, adjuvant chemotherapy demonstrated a progression-free survival benefit when the RS ranged from 16-25. We studied this cohort with the population-based national database.

METHODS

The 2010-2018 National Cancer Database was used to include patients with BC age 18-50 years, N0, M0, RS 16-25, ER+/progesterone receptor±, and HER2-. Patients were divided into two groups on the basis of adjuvant chemotherapy use, and the survival between them was compared.

RESULTS

Adjuvant chemotherapy use was noted in 4,808/15,792 (30.45%) patients. Median RS was 18 and 21 in patients without and with adjuvant chemotherapy, respectively. Factors associated with adjuvant chemotherapy use were higher T stage, poor and moderately differentiated tumors, age <40 years, care at an academic center, Caucasian race, patients undergoing mastectomy, regional lymph node surgery, and radiation therapy. Kaplan-Meier survival at 10 years was better with adjuvant chemotherapy (96.2% v 91.6%). Patients without adjuvant chemotherapy had more adverse outcomes (hazard ratio [HR], 1.683 [95% CI, 1.392 to 2.036]; P < .0001). Subgroup analysis showed that the benefit was significant in patients with RS scores 21-25 (HR, 1.953 [95% CI, 1.295 to 2.945]), ductal histology (HR, 1.521 [95% CI, 1.092 to 2.118]), Caucasian race (HR, 1.655 [95% CI, 1.180 to 2.322]), and 41-50 years age group (HR, 1.732 [95% CI, 1.244 to 2.411]).

CONCLUSION

Our study showed an overall survival benefit for adjuvant chemotherapy use in patients with ER-positive, N0 premenopausal BC patients, age less than 50 years, with an intermediate RS score, particularly 21-25.

A Quality Improvement Initiative for Echocardiogram Ordering Patterns in an Academic Hospital

Background Appropriate Use Criteria (AUC) for echocardiography are a useful tool to deliver quality healthcare. Our quality-based interventional study was designed to assess the trends in appropriate utilization rates for echocardiography in our institution and improve adherence to the AUC criteria for transthoracic echocardiograms (TTE). Methodology A prospective, time series analysis was conducted at the Upstate University Hospital for the months of July 2019 and August 2020. A chart analysis was performed on 620 consecutive inpatients who underwent TTE for the month of July 2019. We assessed the trends of the appropriate ordering of TTEs. We then updated our order form incorporating the 42 most common appropriate indications. A post-intervention chart analysis was performed on all inpatient TTEs ordered for the month of August 2020 (n = 410). The appropriateness of the TTE for the entire group was determined based on the true indication per chart review. The primary outcome was the proportion of appropriate and inappropriate TTEs ordered. Secondary outcomes included assessing for concordance between the indication on the order requisition form and by chart review. A p-value <0.05 was considered significant. Results Using the 2011 AUC for the entire group, 81% of the pre-intervention TTEs and 79.5% of the post-intervention TTEs were appropriate (p = 0.55). There was a statistically significant reduction in the number of discordant TTE orders before and after the intervention (p < 0.01). In addition, we noted increased appropriateness of TTEs in the concordant group both pre and post-intervention. Conclusions Our study demonstrates a significant increase in the concordance between the TTE order sheet and actual indication per chart review with the intervention. This can translate into improved scanning and physician reading quality and time, thereby increasing focus on areas of interest according to the true indication. There was no significant increase in the appropriate TTEs ordered.

Descriptive Analysis and Factors Influencing Survival in Patients With Primary Cutaneous Gamma-Delta T Cell Lymphoma. A Retrospective National Cancer Database Study

BACKGROUND

Gamma delta T cells gives rise to a rare malignancy called Primary cutaneous Gamma-Delta T cell lymphoma (PCGDTCL).

METHODS

From the National Cancer Database (NCDB), 110 (0.015%) patients with PCGDTCL were identified.

RESULTS

Males aged >60 years were the commonest cohort. Caucasian race was the most common (Caucasian: 79.09%, African American:16.36%). Most patients were diagnosed at stage 1 (52.33%), followed by stage 4 (30.23%). On analyzing income categories, <$48,000 group had 48.15% stage 4 (13/27) and 40.74% (11/27) stage 1. Overall survival (OS) of the study group at 3 years by Kaplan-Meier (KM) analysis was 46.6%. African American race (37.5%), income of <$48,000 (27.6%) and government insurance (38.8%) had lower survival rates in KM analysis. In the adjusted hazard ratio (HR) analysis, only age <=40 years compared to >60 years (0.165 [0.036, 0.768], P= .0217) reached significance. Although the group that did not receive any chemotherapy or radiation seemed to have a better survival by KM analysis at 74.3% at 3 years, significance was not seen in the adjusted HR estimates and majority of the patients in this group were stage 1. This group may have received topical treatments which may have not been captured in NCDB. Adjusted analysis also revealed chemoradiation to have a lower mortality risk compared to chemotherapy alone (0.229 [0.079, 0.670], P = .0071), suggesting that aggressive strategies may be required for management when needed.

CONCLUSION

Socioeconomic disparities significantly impact access to healthcare and are of particular importance in rare lymphomas.

Association of Molecular Profiles and Mutational Status With Distinct Histological Lung Adenocarcinoma Subtypes. An Analysis of the LACE-Bio Data

BACKGROUND

Adjuvant chemotherapy (AC) is indicated for stage II and stage III lung adenocarcinomas (ADC). Using the LACE Bio II database, we analyzed the distribution of various mutations across the subtypes of ADCs and studied the prognostic and predictive roles of PD-L1, TMB, and Tumor Infiltrating Lymphocytes (TILs).

MATERIALS AND METHODS

Clinical and genomic data from the LACE Bio II data were extracted. Patients were divided into ADC subtypes, in which the grouping was done based on their known clinical behavior (Lepidic [LEP], Acinar/Papillary [ACI or PAP], Micropapillary/Solid [MIP or SOL], Mucinous [MUC] and Others). Kaplan-Meier (KM) and log-rank test were used to compare survival based on PD-L1, TMB, TILs and combinations of TMB with PD-L1 and TILs. Adjusted Hazard Ratios (HR) were analyzed with Overall Survival (OS), Disease-Free Survival (DFS) and Lung Cancer-Specific Survival (LCSS) as endpoints.

RESULTS

A total of 375 ADC patients were identified. MIP/SOL was the subtype most commonly positive for various biomarkers. PD-L1 Negative/high TMB was associated with better outcomes in terms of OS (HR = 0.46 [0.23-0.89], P = .021) and DFS (HR = 0.52 [0.30-0.90], P = .02), relative to PD-L1 Negative/low TMB. High TMB predicted worse outcome with AC use in terms of OS (ratio of hazard ratio rHR = 2.75 [1.07-7.04], P = .035). Marked TILs had better outcome with AC for DFS (rHR = 0.22 [0.06-0.87], P = .031 and LCSS (rHR = 0.08 [0.01-0.66], P = .019) respectively. There was also a beneficial effect of AC among patients with Marked TILs/low TMB in terms of DFS (rHR = 0.06 [0.01-0.53], P = .011).

CONCLUSION

High TMB has a prognostic role in resectable lung ADC. The high TMB group had a poor outcome with AC, suggesting that this group may be better served with immune checkpoint therapy.

Genomic landscape of clinically advanced KRAS wild-type pancreatic ductal adenocarcinoma

Introduction

KRAS mutation is a common occurrence in Pancreatic Ductal Adenocarcinoma (PDA) and is a driver mutation for disease development and progression. KRAS wild-type PDA may constitute a distinct molecular and clinical subtype. We used the Foundation one data to analyze the difference in Genomic Alterations (GAs) that occur in KRAS mutated and wild-type PDA.

Methods

Comprehensive genomic profiling (CGP) data, tumor mutational burden (TMB), microsatellite instability (MSI) and PD-L1 by Immunohistochemistry (IHC) were analyzed.

Results and discussion

Our cohort had 9444 cases of advanced PDA. 8723 (92.37%) patients had KRAS mutation. 721 (7.63%) patients were KRAS wild-type. Among potentially targetable mutations, GAs more common in KRAS wild-type included ERBB2 (mutated vs wild-type: 1.7% vs 6.8%, p <0.0001), BRAF (mutated vs wild-type: 0.5% vs 17.9%, p <0.0001), PIK3CA (mutated vs wild-type: 2.3% vs 6.5%, p <0.001), FGFR2 (mutated vs wild-type: 0.1% vs 4.4%, p <0.0001), ATM (mutated vs wild-type: 3.6% vs 6.8%, p <0.0001). On analyzing untargetable GAs, the KRAS mutated group had a significantly higher percentage of TP53 (mutated vs wild-type: 80.2% vs 47.6%, p <0.0001), CDKN2A (mutated vs wild-type: 56.2% vs 34.4%, p <0.0001), CDKN2B (mutated vs wild-type: 28.9% vs 23%, p =0.007), SMAD4 (mutated vs wild-type: 26.8% vs 15.7%, p <0.0001) and MTAP (mutated vs wild-type: 21.7% vs 18%, p =0.02). ARID1A (mutated vs wild-type: 7.7% vs 13.6%, p <0.0001 and RB1(mutated vs wild-type: 2% vs 4%, p =0.01) were more prevalent in the wild-type subgroup. Mean TMB was higher in the KRAS wild-type subgroup (mutated vs wild-type: 2.3 vs 3.6, p <0.0001). High TMB, defined as TMB > 10 mut/mB (mutated vs wild-type: 1% vs 6.3%, p <0.0001) and very-high TMB, defined as TMB >20 mut/mB (mutated vs wild-type: 0.5% vs 2.4%, p <0.0001) favored the wild-type. PD-L1 high expression was similar between the 2 groups (mutated vs wild-type: 5.7% vs 6%,). GA associated with immune checkpoint inhibitors (ICPIs) response including PBRM1 (mutated vs wild-type: 0.7% vs 3.2%, p <0.0001) and MDM2 (mutated vs wild-type: 1.3% vs 4.4%, p <0.0001) were more likely to be seen in KRAS wild-type PDA.

Metabolic syndrome is independently associated with improved overall survival to first-line therapy with immune checkpoint inhibitors in non-small cell lung cancer

Background

Many co-existing medical conditions may affect the outcome in patients treated with immune checkpoint inhibitors for advanced cancer. There is currently not any information on whether metabolic syndrome (MetS) impacts the clinical outcome in patients treated with immune checkpoint inhibitors (ICIs) for advanced non-small cell line cancer (NSCLC).

Methods

We carried out a single-center retrospective cohort study to determine the effects of MetS on first-line ICI therapy in patients with NSCLC.

Results

One hundred and eighteen consecutive adult patients who received first-line therapy with ICIs and had adequate medical record information for the determination of MetS status and clinical outcomes were included in the study. Twenty-one patients had MetS and 97 did not. There was no significant difference between the two groups in age, gender, smoking history, ECOG performance status, tumor histologic types, pre-therapy use of broad-spectrum antimicrobials, PD-L1 expression, pre-treatment neutrophil:lymphocyte ratio, or proportions of patients who received ICI monotherapy or chemoimmunotherapy. With a median follow-up of 9 months (range 0.5-67), MetS patients enjoyed significantly longer overall survival (HR 0.54, 95% CI: 0.31-0.92) (p = 0.02) but not progression-free survival. The improved outcome was only observed in patients who received ICI monotherapy and not chemoimmunotherapy. MetS predicted for higher probability of survival at 6 months (p = 0.043) and 12 months (p = 0.008). Multivariate analysis indicated that, in addition to the known adverse effects of use of broad-spectrum antimicrobials and the beneficial effects of PD-L1 (Programmed cell death-ligand 1) expression, MetS was independently associated with improved overall survival but not progression-free survival.

Conclusions

Our results suggest that MetS is an independent predictor of treatment outcome in patients who received first-line ICI monotherapy for NSCLC.

Intestinal barrier functions in hematologic and oncologic diseases

The intestinal barrier is a complex structure that not only regulates the influx of luminal contents into the systemic circulation but is also involved in immune, microbial, and metabolic homeostasis. Evidence implicating disruption in intestinal barrier functions in the development of many systemic diseases, ranging from non-alcoholic steatohepatitis to autism, or systemic complications of intestinal disorders has increased rapidly in recent years, raising the possibility of the intestinal barrier as a potential target for therapeutic intervention to alter the course and mitigate the complications associated with these diseases. In addition to the disease process being associated with a breach in the intestinal barrier functions, patients with hematologic and oncologic diseases are particularly at high risks for the development of increased intestinal permeability, due to the frequent use of broad-spectrum antibiotics and chemoradiation. They also face a distinct challenge of being intermittently severely neutropenic due to treatment of the underlying conditions. In this review, we will discuss how hematologic and oncologic diseases are associated with disruption in the intestinal barrier and highlight the complications associated with an increase in the intestinal permeability. We will explore methods to modulate the complication. To provide a background for our discussion, we will first examine the structure and appraise the methods of evaluation of the intestinal barrier.

Genomic landscape of metastatic breast cancer (MBC) patients with methylthioadenosine phosphorylase (MTAP) loss

INTRODUCTION

Homozygous deletion of MTAP upregulates de novo synthesis of purine (DNSP) and increases the proliferation of neoplastic cells. This increases the sensitivity of breast cancer cells to DNSP inhibitors such as methotrexate, L-alanosine and pemetrexed.

MATERIALS AND METHODS

7,301 cases of MBC underwent hybrid-capture based comprehensive genomic profiling (CGP). Tumor mutational burden (TMB) was determined on up to 1.1 Mb of sequenced DNA and microsatellite instability (MSI) was determined on 114 loci. Tumor cell PD-L1 expression was determined by IHC (Dako 22C3).

RESULTS

208 (2.84%) of MBC featured MTAP loss. MTAP loss patients were younger (p = 0.002) and were more frequently ER- (30% vs. 50%; p < 0.0001), triple negative (TNBC) (47% vs. 27%; p < 0.0001) and less frequently HER2+ (2% vs. 8%; p = 0.0001) than MTAP intact MBC. Lobular histology and CDH1 mutations were more frequent in MTAP intact (14%) than MTAP loss MBC (p < 0.0001). CDKN2A (100%) and CDKN2B (97%) loss (9p21 co-deletion) were significantly associated with MTAP loss (p < 0.0001). Likely associated with the increased TNBC cases, BRCA1 mutation was also more frequent in MTAP loss MBC (10% vs. 4%; p < 0.0001). As for immune checkpoint inhibitors biomarkers, higher TMB >20 mut/Mb levels in the MTAP intact MBC (p < 0.0001) and higher PD-L1 low expression (1-49% TPS) in the MTAP loss MTAP (p = 0.002) were observed.

CONCLUSIONS

MTAP loss in MBC has distinct clinical features with genomic alterations (GA) affecting both targeted and immunotherapies. Further efforts are necessary to identify alternative means of targeting PRMT5 and MTA2 in MTAP-ve cancers to benefit from the high-MTA environment of MTAP-deficient cancers.

Abstract P2-23-09: Ultra-high Tumor Mutation Burden in Metastatic/Clinically Advanced Breast Cancer (MBC)

Background: High (HTMB) tumor mutation burden (TMB) defined as ≥10 mutations/megabase (Mb) identifies breast cancer patients who could benefit from pembrolizumab. The higher the TMB the greater the likelihood of benefit. The goal of this analysis was to determine the frequency and genomic landscape of MBC with ultra-high TMB (UHTMB) defined as a TMB &gt; 20 mutations/Mb. Design 2,049 MBC patients (pts) underwent hybrid capture based comprehensive genomic profiling for genomic alterations (GA) in at least 324 genes including determination of TMB to guide therapy decisions using the FoundationOne®CDx assay. ER, PR and HER2 expression were abstracted from submitted pathology reports. Results: 165 of 2049 MBC (8.1%) had HTMB &gt; 10 mutations/Mb, among these 45 (2.2% of all cases) had UHTMB. When compared with the 2,004 non-UHTMB MBC pts with TMB &lt; 20 mutations/Mb, the 45 UHTMB pts were older (mean 64.6 yrs vs 58.2 yrs; p&lt;.0001), more often had lobular histology (40.00% vs 14.5%; p&lt;.0001) and ER+ disease (86.6% vs 70.0%), had higher average driver GA/tumor (9.84 vs 5.7; p&lt;.0001), and less often had TNBC (13.3% vs 27.0%; p=.041) compared to non-UHTMB high cancers. There were no significant differences in ancestry. Mutation signature analysis revealed that APOBEC was predominant in UHTMB samples (82.5%) with a minor portion with an MMR signature (10%), however, MSI-H status was significantly higher in UHTMB high cases (11.6% vs 0.40%; p&lt;.0001). GA more frequently identified in UHTMB cases included CDH1 (45.50% vs 14.32%; p&lt;.0001), PIK3CA (81.80% vs 37.86%; p&lt;.0001), CDKN2A (11.40% vs 3.19%; p=.017), ARID1A (25.00% vs 5.01%; p&lt;.0001) and NF1 (20.50% vs 5.94%; p=.0014). PD-L1 (CD274) gene amplification (2.3% vs 1.3%) or protein expression by the Ventana SP142 assay (57.14% vs 51.10%) were not significantly different. Conclusions: UHTMB MBC is a rare but clinically important subset in breast cancer that could have high response rates to single agent pembrolizumab. This phenotype is driven by APOBEC mutagenesis, more often seen in ER+ lobular cancers, and have higher frequencies of MSI-high status and mutations in CDH1 and PIK3CA.

Citation Format: Kristina Fanucci, maryam lustberg, Neal Fischbach, Maureen Pelletier, Abirami Sivapiragasam, Prashanth Ashok Kumar, Mansi Kallem, Natalie A. Danziger, Ethan Sokol, Smruthy Sivakumar, Dean Pavlick, Jeffrey S. Ross, Lajos Pusztai. Ultra-high Tumor Mutation Burden in Metastatic/Clinically Advanced Breast Cancer (MBC) [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 P2-23-09.

Abstract P1-01-02: The impact of adjuvant chemotherapy on overall survival in hormone and node positive breast cancer patients with an Oncotype Dx score of 25 or less. A NCDB analysis

Background: The RxPONDER trial showed that in premenopausal breast cancer (BC) subjects who were hormone receptor positive (HR+), N1 lymph node status and had an OncotypeDx (RS) score ≤ 25, the use of adjuvant chemotherapy (AC) along with endocrine therapy (ET) had better disease free and distant relapse free survival than ET alone. Using a large national database, we wanted to see if adding AC improved overall survival in a similar cohort of node positive BC patients.

Methods: The 2004-2018 National Cancer Database was used to include female BC patients aged 18-50 years. Inclusion criteria were N1-N3 lymph node status, M0 patients with any T stage, RS ≤ 25, HR+ and HER2-. Patients who received neoadjuvant chemotherapy were excluded. Logistic regression was used to evaluate AC utility trends. Kaplan-Meier (KM) and multivariate (MV) propensity score (PS) weighted Cox model were used to compare survival between patients with and without AC use.

Results: 8628 women were included of which only 3519 (40.8%) received AC (AC+). 5109 (59.2%) did not receive AC (AC-). AC+ had the following age distribution: (18-40 years: 23.73%, 41-50 years: 76.27%), while AC- had the following: (18-40 years: 15.15%, 41-50 years: 84.85%). RS score distribution are as follows: AC+(0-11: 17.56%, 12-25: 82.44%), AC-(0-11: 35.49%, 12-25: 64.51%). Most of the cohort received ET (AC+: 94.74%, AC-: 93.25%) and majority were N1 (AC+: 92.61%, AC-: 98.9%). Factors associated with AC use includes caucasian race [african american vs caucasian: 0.777(0.647,0.934), p=0.0072], higher stage [II vs I: 1.825(1.598,2.084), p=&lt; 0.0001, III vs I: 3.199(1.593,6.426), p=0.0011] and higher grade [G3 vs G1: 2.261(1.886,2.711), G2 vs G1: 1.467(1.301,1.655), p&lt; 0.0001], radiation (RT) use [1.758(1.544,2.002), p&lt; 0.0001], younger age [40-50 vs 18-40: 0.684(0.542,0.863), p=0.0013], higher RS [12-25 vs 0-11: 2.325(2.065,2.618), p&lt; 0.0001], mastectomy [vs partial surgery: 1.668(1.469,1.894), p&lt; 0.0001] and N2N3 nodal stage [N2N3 vs N1: 2.688(1.423,5.079), p=0.0023].

KM curves showed that AC+ had better survival at 10 years (93% vs 91%) (Table 1). Hazard Ratio (HR) comparison between the 2 groups favored AC+ [0.602(0.482,0.751), p&lt; 0.0001] (Table). Subgroup analysis for overall mortality benefits from AC+, using MV adjusted HR showed favorable results in caucasian race [0.512(0.348,0.752)], both age groups of 18-40 years [0.429(0.217,0.847) and 40-50 years [0.585(0.394,0.869)], both poorly differentiated [0.404(0.186,0.874)] and well-differentiated [0.386(0.165, 0.903] grades and RS 12-25 [0.549(0.379,0.795)]. RS 0-11 did not reach significance [0.555(0.216,1.423].

Discussion: Based on our analysis, AC use was noted in 40.8% of young, lymph node and HR+ BC patients with an RS score of 0-25. This group of patients had an overall survival advantage of around 40% with AC use, further supporting the findings of the RxPONDER trial. This benefit is of particular significance in patients with a RS of 12-25. The survival advantage was present in all patients less than 50 years, regardless of the age subgroup used in our analysis. Possible mechanisms leading to these outcomes include direct cytotoxic effects and menopausal induction with AC use. Limitations of our study include the use of non-population-based data and the possibility of cofounding despite the use of PS matching. Moving forward, AC use along with hormone therapy may become standard practice in young HR + BC patients with lymph node involvement, regardless of the RS score.

Table 1 Survival difference between AC+ and AC-. KM-Kaplan-Meier, AC-Adjuvant Chemotherapy, HR-Hazard Ratio, MV-Multivariate, PS-propensity score.

Citation Format: Prashanth Ashok Kumar, Dongliang Wang, Danning Huang, Abirami Sivapiragasam. The impact of adjuvant chemotherapy on overall survival in hormone and node positive breast cancer patients with an Oncotype Dx score of 25 or less. A NCDB analysis [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 P1-01-02.

Radiation Recall Dermatitis Following Treatment With Pembrolizumab: A Case Report and Review of the Literature

Radiation recall dermatitis is an inflammatory reaction of the skin that may infrequently occur in areas of the skin that have been previously treated with radiation therapy. This is thought to be due to a triggering agent administered after radiation therapy which leads to an acute inflammatory reaction, manifesting as a skin rash. We present the case of a 58-year-old male with recurrent invasive squamous cell carcinoma of the tongue, previously treated with chemotherapy and radiation therapy, who presented with progression of his disease. He was treated with pembrolizumab and subsequently developed a new-onset facial rash over the previously treated radiation field. The distribution of the rash was suggestive of radiation recall dermatitis. A biopsy showed dermal necrosis without evidence of dermatitis, vasculitis, or infectious process. This case highlights the incidence of a rare complication of immune checkpoint inhibitor therapy and emphasizes the need for careful monitoring for radiation recall dermatitis.

Current Trends in the Management of Epithelial Lacrimal Gland Tumors: A Retrospective National Cancer Database Analysis

Background: Lacrimal gland tumors are rare with data limited to very few large studies. Contemporary strategies like orbit sparing surgeries and neoadjuvant intraarterial chemotherapy remain controversial.

Methods: This is a retrospective cohort analysis of epithelial lacrimal gland tumors from the 2004-2016 National Cancer Database. Patients were stratified based on the type of surgery (limited vs destructive) and various treatment modalities employed.

Results: Squamous cell carcinoma (33.48%) and adenoid cystic carcinoma (29.45%) were the commonest histologies (N=669). Comparison of limited (46.33%) vs destructive procedures (53.11%) among 482 patients did not show any survival difference, nor the comparison between surgery vs ± chemotherapy vs ± radiotherapy among 472 patients.

Conclusion: Squamous cell carcinoma and adenoid cystic carcinoma are the commonest types of lacrimal gland tumors seen in our study. Tumor spread from adjacent sites may have contributed to the higher percentage of squamous cell carcinomas seen. The type of surgery or chemoradiation use did not alter survival.

Genomic landscape of non-small-cell lung cancer with methylthioadenosine phosphorylase (MTAP) deficiency

INTRODUCTION

New treatment strategies for advanced non-small-cell lung carcinoma (NSCLC) include synthetic lethality targets focused on protein arginine methyl transferases such as PRMT5 that exploit the impact of genomic loss of methylthioadenosine phosphorylase (MTAP).

METHODS

Twenty nine thousand three hundred seventy nine advanced NSCLC cases underwent hybrid-capture based comprehensive genomic profiling between June 1, 2018 and May 31, 2020. PD-L1 expression was determined by immunohistochemistry (Dako 22C3 PharmDx assay).

RESULTS

13.4% (3928/29,379) NSCLC cases exhibited MTAP loss distributed in adenocarcinoma (59%), squamous cell carcinoma (22%), NSCLC not otherwise specified (16%), and 1% each for large-cell neuroendocrine, sarcomatoid, and adenosquamous carcinoma. Statistically significant differences in mitogenic driver alterations included more KRAS G12C mutations in MTAP-intact versus MTAP-lost (12% vs. 10%, p = 0.0003) and fewer EGFR short variant mutations in MTAP-intact versus MTAP-lost NSCLC (10% vs. 13%, p < 0.0001). Statistically significant differences in currently untargetable genomic alterations included higher frequencies of TP53 (70% vs. 63%, p < 0.0001) and RB1 inactivation (10% vs. 2%, p < 0.0001) in MTAP-intact compared to MTAP-lost NSCLC. SMARCA4 inactivation (7% vs. 10%, p < 0.0001) was less frequent in MTAP-intact versus MTAP-lost NSCLC. Alterations in ERBB2, MET, ALK, ROS1, and NTRK1 did not significantly differ between the two groups. Predictors of immunotherapy efficacy were higher in MTAP-intact versus MTAP-lost NSCLC including tumor mutational burden (9.4 vs. 8.6 mut/Mb, p = 0.001) and low (30% vs. 28%, p = 0.01) and high PD-L1 (32% vs. 30%, p = 0.01) expression. Alterations in biomarkers potentially predictive of immune checkpoint inhibitor resistance (STK11, KEAP1, and MDM2) were similar in the two groups.

CONCLUSIONS

MTAP loss occurs in 13% of NSCLC, supporting the development of targeted therapies to exploit PRMT5 hyper-dependence. MTAP loss is accompanied by small differences in targeted and immunotherapy options which may impact future combination strategies.

Utility of adjuvant chemotherapy in early-stage, estrogen receptor-positive breast cancer patients under 50 years with a 21-gene recurrence-score of 16-25: A retrospective analysis using the National Cancer Database

e12501

Background: The TAILORx trial showed that addition of adjuvant chemotherapy (AC) to endocrine therapy (ET) had no advantage in estrogen receptor (ER)+, HER2-, node negative (N0) breast cancer (BC) patients with an intermediate (11-25) 21-gene recurrence-score (RS). However, a subgroup analysis revealed that in women ≤ 50 years, AC had a lower rate of distant recurrence if the RS was 16-25. Using a large national database, we studied the utilization of AC in the aforementioned subset. Methods: The 2004-2018 National Cancer Database BC cohort was used to include female patients of 18-50 years. Inclusion criteria were N0, M0 patients with any T stage, RS 16-25, ER+/PR± and HER2-. Patients who received neoadjuvant chemotherapy were excluded. Logistic regression was used to evaluate AC utility trends. Kaplan-Meier (KM) and multivariate (MV) propensity score (PS) weighted Cox model were used to compare survival between patients without and with AC use. Results: Of the 15,792 patients, 4808 (30.45%) received AC. Median RS was 18 and 21 in patients without and with AC. Factors associated with AC use were higher T stage, poor and moderately differentiated tumors, age <40, care at an academic center, Caucasian race, patients undergoing mastectomy, regional lymph node (RLN) surgery, ET and Radiation Therapy (RT). KM survival at 10 years was better with AC [96.2% vs 91.6%]. Patients without AC had worse survival [Hazard Ratio (HR)=1.683, 95% Confidence Interval (CI): 1.392-2.036, p<0.0001] (Table). Conclusions: In this analysis,AC use had a 5% improvement in 10 year overall survival, in contrast to TAILORx trial which only showed a disease free survival benefit. Whether the benefit was due to direct cytotoxicity or ovarian function suppression effect of AC remains to be seen. In clinical practice, AC use is determined based on patient and tumor characteristics. Limitations of our study include non-population-based data and the possibility of cofounding despite the use of PS matching. [Table: see text]

A Rare Cause of Chronic Hip Pain From PEComa: An Aggressive Mesenchymal Sarcoma

Perivascular epithelioid cell tumors (PEComas) are related to the tuberous sclerosis complex (TSC) and are commonly benign. When malignant, they can be aggressive with local invasion and metastatic spread. Conventional PEComas do not have TFE3 gene rearrangement and are associated with TSC with a preference for an occurrence at a younger age. We report a case of a young male who had progressive chronic hip pain and was found to have a TFE3-associated PEComa in his pelvic region.

Liposomal Daunorubicin and Cytarabine, a Potential Therapy for Blastic Plasmacytoid Dendritic Cell Neoplasm

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare aggressive malignancy with poor outcomes. Although novel options like tagraxofusp, a CD123-directed cytotoxin, has emerged and is promising, treatment options are very limited in the relapsed and recurrent setting. We present a case of refractory BPDCN in a 62-year-old man who showed a complete bone marrow response to liposomal daunorubicin and cytarabine (vyxeos).

Primary Neuroendocrine Tumor of the Scrotum: An Uncommon Site for a Rare Tumor

Neuroendocrine tumors (NETs) are a heterogeneous group of tumors developing from neural crest cells, with numerous sites of origin, commonly the gastrointestinal and genitourinary tracts. NETs of the genitourinary tract are more common in women. Small cell carcinoma of the prostate or testicular carcinoid are the NETs in male. In this article, we present a rare case of NET of the scrotum. Our patient was a 47-year-old male with a history of complicated pilonidal cysts resulting in chronic scrotal wounds. Biopsy of a large nonhealing scrotal wound revealed a high-grade neuroendocrine carcinoma with features most suggestive of small cell carcinoma. Presenting with advanced disease at diagnosis, he was started on systemic therapy and unfortunately progressed through multiple lines of treatment, including CAPTEM (capecitabine and temozolomide). Unfortunately, due to multiple logistical reasons, the patient was unable to receive the then off-label immunotherapy based on DART (Dual Anti-CTLA-4 and Anti-PD-1 Blockade in Rare Tumors) trial. He, unfortunately, succumbed to his disease within months of diagnosis.

Abstract PS13-08: Predictors and long-term outcome of pathologic complete response in patients receiving neoadjuvant chemotherapy for breast cancer - an NCDB analysis

Background:

Among women with high-risk early stage breast cancer, neoadjuvant chemotherapy (NCT) is increasingly utilized. The Collaborative Trials in Neoadjuvant Breast Cancer working group studied 13,000 patients from 12 large trials involving NCT and concluded that pathologic complete response (pCR) resulted in significantly better outcomes with respect to both disease recurrence and mortality. This National Cancer Database (NCDB) study aims to gather patient and tumor characteristics to further identify prognosticators of pCR, and determine which subgroups achieving pCR have the greatest survival benefit.

Methods:

Retrospective analysis using NCDB data from 2004-2015 identified 46,836 women ≥18 years with stage I to III breast cancer who received NCT. Achievement of pCR was defined as ypT0 ypN0 or ypT0/is ypN0. Tumor and patient characteristics were evaluated, and multivariate logistic regression was used to calculate odds ratio (OR) of pCR. Kaplan-Meier curves were constructed for calculation of overall survival (OS) at 5 years. Hazard ratios (HR) were estimated from Cox models. Propensity score weighting was used to adjust for confounding effects of various factors on survival via Cox regression.

Results:

Patients were more likely to achieve pCR with ductal vs. lobular histology (OR 1.62 [95% CI 1.414-1.872]), grade 3 vs. 1 (OR 1.606 [95% CI 1.394-1.849]), stage 3 vs. 1 (OR 1.76 [95% CI 1.623-1.908]), ER+PR- vs. ER+PR+ (OR 2.004 [95% CI 1.855-2.165]), ER-PR- vs. ER+PR+ (OR 2.572 [95% CI 2.425-2.729]), age &lt;60 (OR 1.43 [95% CI 1.32-1.55]), Charlson-Deyo combined comorbidity (CDCC) score of 0 vs. 2 (OR 1.27 [95% CI 1.04-1.54]), and private insurance vs. uninsured (OR 1.24 [95% CI 1.09-1.41]). HR for death adjusted by propensity score in patients attaining pCR vs. non-pCR was 0.346 (95% CI 0.325-0.368) for the overall cohort, 0.591 (95% CI 0.513-0.681) for ER+PR+ patients, 0.373 (95% CI 0.315-0.442) in the ER+PR- group, and 0.307 (95% CI 0.284-0.332) for ER-PR- patients. Achieving pCR conferred better OS in all subgroups with higher magnitude in hormone negative patients (table 1).

Conclusions:

This study not only highlights factors associated with achieving pCR after neoadjuvant chemotherapy for breast cancer, but also demonstrates that attaining pCR reduces the risk of death by 65.4% in all patients regardless of receptor subtype. Furthermore, the survival curve increasingly separates with time. Our study reveals an intriguing observation that ER+PR+ patients who attain pCR have 40.9% decreased mortality compared to non-pCR. Limitations of this analysis include the lack of HER2 status and that conclusions are made from non-population based observational data. Despite utilization of propensity score weighting, there may have been confounders that were not adjusted for by the multivariate model. Future analysis is needed to identify HER2 status, as HER2-positive patients may have contributed to the OS benefit in the subgroups. Nonetheless, these data are among the first to suggest that hormone-positive patients derive long-term survival benefit from achievement of pCR, albeit to a lesser extent than hormone-negative subtypes.

Table 1. 5-year survival estimates from Kaplan-Meier analysispCRNon-pCRSurvival differencep (95% CI)All patients0.88500.73840.14657&lt;0.0001 (0.1364-0.1567)ER+PR+0.90300.81170.09121&lt;0.0001 (0.0744-0.1079)ER+PR-0.89620.70740.18879&lt;0.0001 (0.1609-0.2166)ER-PR+0.88070.63880.24198&lt;0.0001 (0.1719-0.3120)ER-PR-0.87570.64660.22913&lt;0.0001 (0.2131-0.2451)

Citation Format: Lauren Mikesell Panebianco, Prashanth Ashok Kumar, Shreya Sinha, Dongliang Wang, Danning Huang, Abirami Sivapiragasam. Predictors and long-term outcome of pathologic complete response in patients receiving neoadjuvant chemotherapy for breast cancer - an NCDB analysis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-08.

Associated factors and outcomes of delaying adjuvant chemotherapy in breast cancer by biologic subtypes: a National Cancer Database study

Purpose

Several studies have evaluated the role of delayed initiation of adjuvant chemotherapy (AC) in breast cancer (BC), but the results have remained controversial and an optimal time has not been defined. Our aim was to determine the effect of time to starting AC from the date of surgery on survival of BC patients, based on estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, using data from the National Cancer Database (NCDB).

Methods

A total of 332,927 Stage I–III BC patients who received AC from 2010 to 2016 were analyzed. We included all ER, PR and HER2 statuses and excluded patients with stage 4 and stage 0 (DCIS) disease. The cohort was divided into five groups based on the time of initiating AC from the date of the most definitive surgery i.e., ≤ 30 days, 31–60 days, 61–90 days, 91–120 days and > 120 days. They were further divided into five subgroups based on the receptor status.

Results

Hazard ratio (HR) estimates and Kaplan–Meier (KM) analysis shows that starting AC by 31–60 days shows the best survival outcome in all the subtypes, except in hormone positive/HER2 negative BC in which 31–60 days and 61–90 days have similar outcomes.

Conclusions

After surgery for BC, it takes around 4–6 weeks to begin AC and delay in initiating the same leads to poor outcomes. Our results are particularly significant in triple-negative breast cancer (TNBC), similar to prior studies showing a benefit to starting AC as early as possible after surgery.

Predictive Biomarkers for Immune Checkpoint Inhibitors in Metastatic Breast Cancer

We examined a large dataset of female metastatic breast cancers (MBCs) profiled with comprehensive genomic profiling (CGP) to identify the prevalence and distribution of immunotherapy responsiveness-associated biomarkers. DNA was extracted from 3831 consecutive MBCs: 1237 (ERpos /HER2neg ), 1953 ERneg /HER2amp , and 641 triple-negative breast cancer (TNBC). CGP was performed using the FoundationOne® or FoundationOne® CDx NGS assay. Tumor mutational burden (TMB) and microsatellite instability (MSI) were determined in a subset of cases. PD-L1 expression in immunocytes in a subset of cases was determined by immunohistochemistry using the companion diagnostic VENTANA PD-L1 SP142 Assay. The median age of the cohort was 54 years (range 20-89). Genomic alterations (GAs)/tumor were similar (range: 5.9-7.3). Markers of potential immune checkpoint inhibitor (ICPI) benefit included: CD274 (PD-L1) amplification (1%-3%), BRAF GA (1%-4%), TMB of ≥10 mutations/Mb (8%-12%), MSI-high (0.1%-0.4%), PBRM1 GA (1%), and positive PD-L1 staining of immunocytes ranging from 13% in ERpos /HER2neg and 33% in ERneg /HER2amp to 47% in the TNBC group. Potential markers of ICPI resistance included inactivating STK11 GA (1%-2%) and MDM2 amplification (3%-6%). MTOR pathway targets were common with lowest frequency in TNBC. ERBB2 short variant mutations were most frequent ERpos /HER2neg and absent in TNBC. BRCA1/2 GA were least frequent in ERneg /HER2amp . The demonstrations of clinical benefit of immunotherapy in MBC support the need for development and utilization of biomarkers to guide the use of ICPIs for these patients. In addition to guiding therapy selection, CGP shows potential to identify GA linked to response and resistance to ICPI in MBC.

Shewanella algae - A Novel Organism Causing Bacteremia: A Rare Case and Literature Review

Shewanella species are distributed ubiquitously in the soil and water, being common in the marine habitat. Although these bacilli were thought to be rarely pathogenic, there has been an increasing number of reports of them being implicated in a wide variety of clinically significant infections. Three distinct species were initially recognized by MacDonell and Colwell. They were Shewanella putrefaciens, hanedai and benthica. Shewanella algae, which is the most common human clinical isolate, was believed to be a strain of Shewanella putrefaciens by some authors, and was later grouped as a separate and distinct entity. With multi-drug resistance on the rise and the lack of large-scale systemic studies, we describe a case of bacteremia caused by this rare organism. We hope to increase the awareness among care providers on the same.

Kocuria kristinae pneumonia and bacteremia

Kocuria kristinae is an aerobic gram-positive bacterium that is part of the normal skin flora and not a common cause of infection. Here, we present the first reported case of community-acquired pneumonia and bacteremia caused by K. kristinae. The pneumonia was complicated by acute on chronic diastolic heart failure, resulting in acute hypoxic respiratory failure requiring intubation and mechanical ventilation.

Air in the Breast: A Rare Cause of Iatrogenic Pneumomastia

Air in the breast tissue (pneumomastia) is a rare finding, more so without any history of procedures on the breast. We report the case of an 80-year-old lady who was found to have foci of gas in her right breast on a CT scan. On exclusion of other possible causes for the same, it was concluded that the air in the breast tissue was secondary to a peripheral intravenous line placement. To our knowledge, this is the first reported case of pneumomastia as a complication of peripheral intravenous line placement.

Current trends in the management of lacrimal gland tumors: A National Cancer Database study

e18573

Background: Lacrimal Gland (LG) tumors are rare with data limited to very few comparative trials. The original treatment is Orbital Exenteration followed by Radiotherapy (RT). Contemporary strategies like orbit sparing surgeries and Neoadjuvant Intra-arterial Chemotherapy (CT) are gaining popularity but remains controversial given the paucity of data. Our aim was to determine the pathological distribution and compare the treatment modalities used in LG tumors with the help of a large national database. Methods: From the 2004-2016 National Cancer Database (NCDB), we included Epithelial LG tumors. We excluded Lymphomas, Melanomas, Sarcomas and other metastatic lesions. Descriptive statistics, Hazard Ratio (HR) estimates and Kaplan Meier (KM) survival analysis were used. Results: A total of 669 LG tumors were identified. The distribution based on Pathology and treatment strategies used is represented in the table. The point survival estimate comparison between the surgical types and the various treatment groups showed no significance. Conclusions: SCC was the most common histological type. There was no difference in the overall outcome between radical and orbit sparing procedures. Adjuvant RT and adjuvant chemoradiation did not confer any additional survival benefit over surgery alone. Mallen-St Clair et. using the SEER database (321 LG patients) showed that RT improves Disease Specific Survival in SCC. Moving forward, larger population-based studies and prospective trials are needed to determine the most ideal management option. The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The data used in the study are derived from a de-identified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator. [Table: see text]

Debilitating Darier’s Disease and Its Impact on the Quality of Life

Darier's disease (DD) is a rare, autosomal dominant genodermatosis that occurs due to mutations in the ATP2A2 gene on chromosome 12q23-24 that codes for sarco/endoplasmic reticulum calcium ATPase (SERCA), causing desmosomal breakdown and acantholysis. The disease usually persists for life and is characterized by a relapsing-remitting course. It can be challenging to treat and can cause several complications that may result in frequent hospitalizations. Sepsis, with the damaged skin as the portal of entry, and widespread herpes can occur. Studies have shown genetic links and associations between DD and psychiatric conditions like recurrent depression and bipolar disorder. We report the case of a 70-year-old male with a severe form of the condition and highlight his clinical course. We describe the severe nature of his disease that resulted in multiple complications like recurrent bacterial skin infections, significantly impairing his quality of life and leading to his ultimate demise.

Atypical Cardiac Tamponade Manifesting as Left Ventricular Diastolic Collapse: A Case Report

Cardiac tamponade is a medical emergency, the diagnosis of which is predominantly clinical with supportive echocardiographic findings. Echocardiographic findings highly suggestive of cardiac tamponade include chamber collapse, inferior vena cava (IVC) plethora, and respiratory volume/flow variations. The right-sided cardiac chambers are a low-pressure system and are the first to show signs of collapse with high specificity for tamponade. We report the case of a 35-year-old woman who demonstrated left ventricular (LV) diastolic collapse on echocardiogram following a tricuspid valve replacement. Although left-sided chamber collapse with tamponade has been reported with localized pericardial effusions postoperatively, our patient had a large circumferential pericardial effusion. Selective chamber compression can be a presenting sign of postoperative tamponade after cardiac surgery. Our case highlights the importance of recognizing atypical forms of cardiac tamponade to help in early identification and emergent management in such patients.

Hemodynamic Collapse Following Therapeutic Plasma Exchange in a Patient Receiving an Angiotensin Receptor Blocker

Therapeutic plasma exchange (TPE) is a procedure for removal of plasma and its components while leaving behind cellular elements via an apheresis device. It is used in multiple conditions one among which is systemic lupus erythematosus (SLE). Adverse reactions from TPE range from mild hypotension and fever to life-threatening cardiovascular compromise. We report the case of sudden hemodynamic collapse following TPE for a neuropsychiatric lupus flare in a patient on losartan. A 62-year-old Caucasian female with a history of drug-induced lupus presented to the hospital with symptoms of a neuropsychiatric lupus flare. She was initiated on TPE with 5% albumin based on recommendations by her rheumatologist. Shortly after TPE, she became hypotensive with poor response to fluid boluses, requiring pressor support and intubation. These symptoms resolved within 24 hours on supportive measures. This was believed to be due to losartan use on the day of TPE. The medication was discontinued and she had further sessions of TPE with no complications. Angiotensin-converting enzyme (ACE) inhibitors have previously been associated with flushing and hypotension in patients undergoing TPE. Patients undergoing TPE have an activation of the prekallikrein and bradykinin system on contact with the extracorporeal membranes. ACE inhibitors potentiate this reaction by inhibiting bradykinin catabolism. Angiotensin receptor blockers (ARBs) have also been postulated to cause elevated bradykinin levels although data pertaining to the use of ARBs in TPE is limited. We hope to highlight this rare interaction in our case and emphasize the need for further data with regard to the same.

Eyes As the Window to Syphilis: A Rare Case of Ocular Syphilis As the Initial Presentation of Syphilis

In the pre-antibiotic era, neurosyphilis (NS) was common, occurring in 34% of patients with syphilis. Currently, there has been a rising trend in syphilis with HIV-infected patients being more prone to develop NS. Ocular involvement is very rare in NS and accounts for only 1%-5% of the cases in the United States. We report the case of a 53-year-old male with a past medical history of gastroesophageal reflux disease and hyperlipidemia who presented to his ophthalmologist for blurred vision in both eyes. He had been noticing a black spot in the visual field of his left eye for two weeks. He had also noticed a rash on his forearms. His past and social history was significant for treated Lyme disease, having pet cats. He identified as a heterosexual male, married, and with five children. However, on further history taking, he reported a homosexual exposure about five years prior. He denied any history of genital ulcer or penile discharge. On examination at the ophthalmology clinic, he was found to have a visual acuity of 20/20 right eye and 20/100 left eye. Posterior segment examination of the both eyes showed subtle neuritis and vasculitis. Fundus photography revealed subtle neuroretinitis bilaterally. Work up was initiated for inflammatory and infectious causes. His rapid plasma reagin and fluorescent treponemal antibody absorption showed positive titers for syphilis. His presentation was most consistent with ocular syphilis. A lumbar puncture (LP) was done with Venereal Disease Research Laboratory (VDRL) positivity in the spinal fluid. He was therefore initiated on intravenous (IV) penicillin four million units every four hours for 14 days. His ophthalmology follow-up after one month showed both subjective and objective improvement in his visual symptoms. He also followed with the infectious disease team and a repeat LP done three months later showed nonreactive VDRL in cerebrospinal fluid (CSF). Ocular syphilis is increasing in incidence. Clinical presentation is variable, and a high index of suspicion with a low threshold for serological testing are important as early treatment can reverse retinal changes and restore visual acuity. There is a recommendation for CSF examination in all patients with ocular syphilis including HIV-negative cases. There have been studies showing a high CSF abnormal rate in HIV-negative patients with ocular syphilis. The recommended treatment for NS is aqueous crystalline penicillin G (18 to 24 million units per day, administered as three to four million units IV every four hours, or 24 million units daily as a continuous infusion) for 10 to 14 days. Follow-up is a key component of management with neurological examination and LP for CSF VDRL performed three months after treatment and every six months after, until the CSF is nonreactive for VDRL with normal white blood cell count. It is important to be cognizant of the rising trend of ocular syphilis, even in HIV-negative individuals. Early treatment is time sensitive to preventing permanent vision loss. Our case also emphasizes on thorough history taking, even for patients who appear to be at a low risk for sexually transmitted infections.

Primary Mucinous Adenocarcinoma of the Upper Eyelid in an African American Female: A Rare Clinical Entity. A Case Report and Literature Review

Primary mucinous adenocarcinoma (PMA) of the eyelid is a rare eccrine gland cancer with an incidence of 0.07 per million person-years. We report a case of a 62-year-old African American female who presented with a tender lesion over her left upper eyelid which was gradually progressive over four years. It was initially presumed to be benign but histopathology after excision was suggestive of a mucinous colloid carcinoma with positive margins. She underwent repeat excision with wide margins and reconstruction and immunohistochemical studies were suggestive of PMA. Workup for metastatic disease and rare possibility of underlying occult malignancy was negative. PMA is uncommon, more so in the African American population and in females. Given the uncommon occurrence of this tumor and similarities in histopathology to colon and breast cancers, underlying occult malignancies need to be ruled out prior to confirming the diagnosis of PMA. The most effective treatment modalities are Mohs micrographic surgery or excision with frozen section control of margins with regular follow up over a prolonged period of time. However, there are no large clinical studies with regard to treatment and follow up. More literature on this tumor would therefore be beneficial to clinicians.

Does the time to initiate adjuvant chemotherapy effect outcome in patients with breast cancer? A National Cancer Database-based retrospective analysis

e12054

Background: The Early Breast Cancer Trialists Collaborative Group showed that adjuvant therapy for breast cancer (BC) significantly reduces the 5-year recurrence and 15-year mortality rates. After surgery, it usually takes around 4-6 weeks to begin adjuvant chemotherapy and delay in initiating the same is believed to lead to poorer outcomes. A number of studies have sought to evaluate the role of delayed initiation of chemotherapy on survival but results have remained controversial and an optimal time has not been defined. Methods: Our aim was to determine the effect of delay in starting chemotherapy from the date of surgery on survival of patients with early BC using the National Cancer Database (NCDB) data. From the database, we selected patients aged >18 years with stage 1-3 BC who received adjuvant chemotherapy. We included all ER/PR statuses. A total of 544,005 patients were divided into 3 groups based on the time of initiating chemotherapy from the date of surgery i.e., 0-60 days, 60-90 days and >90 days and had a distribution of 38.07%, 35.90% and 26.03 % respectively. Results: Estimates from cox models showed the following adjusted Hazard Ratios(HR): 0-60 days vs >90 days (HR 0.976, CI 0.955-0.998), 60-90 days vs >90 days (HR 0.899, CI 0.879-0.920). Kaplan Meier Survival estimates revealed that the 0-60 days and the 60-90 days groups had a better 10 year survival estimate than the > 90 days group with a p<0.0001. The factors that correlate with delay in initiating adjuvant chemotherapy are African American race, poor Charlson Deyo Score, uninsured or government insurance holders, well differentiated tumors and ER/PR positive status. Conclusions: Based on our analysis from a large national database, we hypothesize that delaying adjuvant therapy for more than 90 days may have worse outcomes due to reasons like rapid growth of micro metastasis following removal of the primary tumor. Thus for stage 1-3 BC, the ideal time to start adjuvant chemotherapy from the date of surgery is before 90 days. Survival estimates from Kaplan-Meier analysis. [Table: see text]

Pancreatic Tuberculosis: A Puzzle for Physicians. A Rare Case and Review of Literature

Pancreatic Tuberculosis is an uncommon form of extra pulmonary tuberculosis that resembles malignancy of pancreas and serve as a diagnostic challenge for physicians. Conservative management with Anti Tuberculosis Therapy (ATT) will suffice for pancreatic tuberculosis whereas a malignancy may require major surgeries which may lead to significant morbidity. Here, we discuss the case of a female patient who presented with abdominal pain and vomiting and is a known case of chronic calcific pancreatitis. Radiological findings were that of malignancy of the pancreas. Enteroscopy showed pus flowing out from the duodenum. Endoscopic Ultrasound (EUS) guided Fine Needle Aspiration Cytology (FNAC) of the pancreas revealed acid fast bacilli. The patient was treated successfully with ATT. Timely diagnosis of this rare form of extra pulmonary tuberculosis can thus help avoid unwanted resections done for presumed malignancy, for which a high index of suspicion is needed.

The Role of Ischemia Modified Albumin as a Biomarker in Patients with Chronic Liver Disease

INTRODUCTION

Chronic Liver Disease (CLD) is characterised by gradual destruction of liver tissue over time. Ischemia Modified Albumin (IMA) is an upcoming biomarker shown to be elevated in conditions associated with ischemia and oxidative stress. Albumin levels are greatly reduced in patients with CLD and studying its alterations will provide essential information regarding the molecular changes occurring to it.

AIM

The study aims to estimate IMA and IMA/Albumin ratio in patients with CLD and to correlate it with parameters assessing liver function and the Model for End Stage Liver Disease (MELD) score.

MATERIALS AND METHODS

The study consisted of 43 CLD patients as test subjects and 28 apparently healthy individuals as controls. Multiple parameters assessing liver function like albumin, bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), Gamma Glutamyl Transpeptidase (GGT), alkaline phosphatase (ALP), Prothrombin Time (PT) INR and creatinine were estimated and the MELD score calculated. Serum IMA expressed as Absorbance Units (ABSU) was estimated using the Albumin Cobalt Binding test (ABT). Student's t-test and correlation coefficient was used for statistical analysis.

RESULTS

Serum IMA was significantly higher in CLD patients (0.5320 ± 0.1677) as compared to the control group (0.3203 ± 0.1257) with a p-value of <0.0001. The IMA/Albumin ratio was also significantly higher (0.2035 ± 0.0970) in patients with CLD compared to control group (0.0714 ± 0.0283) with a p-value of <0.0001. IMA has a negative correlation with albumin. The IMA/Albumin ratio shows positive correlation with MELD score, bilirubin and ALP. There was no correlation with ALT, AST, GGT and PT INR.

CONCLUSION

Decreased serum albumin correlates with increase in IMA in CLD could indicate a qualitative change and not merely a quantitative reduction of albumin. IMA can serve as a biomarker to assess the disease severity and prognosis of CLD patients.

Multiple Biomarkers to Assess the Pathophysiological State in Critically Ill Patients with Sepsis

Sepsis is associated with various metabolic derangements as a consequence of inflammatory response, ischemia and oxidative stress. Four parameters of relevance are procalcitonin (PCT), ischemia modified albumin (IMA) pH and lactate. The study was carried out to highlight the concomitant occurrence of sepsis, ischemia and lactic acidosis, all of which could have deleterious effects on organ function. 26 critically ill patients with a provisional diagnosis of sepsis were the test subjects. The control group had 25 apparently healthy volunteers. PCT, lactate and IMA were assayed. PCT was estimated on an automated analyser using electro-chemiluminescence. Lactate and pH were estimated on a blood gas analyzer. Serum IMA was estimated spectrophotometrically by Albumin Cobalt Binding Test. Statistical tools like students 't' test and Venn diagram were employed to depict the outcome of the study. All critically ill patients had significantly higher IMA levels (0.96746 ± 0.73407) as compared to the control group (0.00728 ± 0.00895) with a p value of <0.0001. The Venn diagram was used to depict the finding that all 26 test subjects had elevated levels of IMA, of which PCT was elevated in 22 and lactate in 20. Both PCT and lactate were abnormal in 17 patients. The most significant observation was that all critically ill patients, irrespective of the presence of sepsis or lactic acidosis had elevated levels of IMA which is clearly indicative of the ubiquitous presence of oxidative stress. The Venn diagram is an elegant representation of the concurrent multiple pathophysiological processes which occur in critically ill patients.

Isolated proximal rupture of flexor digitorum longus tendon in a traumatic open subtalar dislocation

Tendon ruptures associated with ankle fractures and dislocations or subtalar dislocations are very rare entities with only a few reports of these in the literature. We report a case of an open subtalar dislocation and associated isolated proximal rupture of the flexor digitorum longus tendon at the musculotendinous junction, following a relatively low energy trauma. The finding of the avulsed flexor digitorum longus tendon was intraoperative, and management involved thorough washout of the joint and a primary side-to-side tenodesis with the flexor hallucis longus tendon. The patient has made a good functional recovery from his injuries. This case is reported because of the rarity of this combination of injuries and the associated management dilemma with which it presented us.

Synergistic activity between Bacillus thuringiensis Cry1Ab and Cry1Ac toxins against maize stem borer (Chilo partellus Swinhoe)

AIM

To select a toxin combination for the management of maize stem borer (Chilo partellus) and to understand possible mechanism of synergism among Bacillus thuringiensis Cry1A toxins tested.

METHODS AND RESULTS

Three Cry1A toxins were over expressed in Escherichia coli strain JM105 and used for diet overlay insect bioassay against C. partellus neonate larvae, both alone and in combinations. Probit analysis revealed that the three Cry1A toxins tested have synergistic effect against C. partellus larvae. In vitro binding analysis of fluorescein isothiocyanate (FITC)-labelled Cry1A toxins to midgut brush border membrane vesicle (BBMV) shows that increase in toxicity is directly correlated to an increase in binding of toxin mix.

CONCLUSIONS

A high Cry1Ac to Cry1Ab ratio leads to an increase in efficacy of these toxins towards C. partellus larvae and this increase in toxicity comes from an increase in toxin binding.

SIGNIFICANCE AND IMPACT OF THE STUDY

Use of Cry1Ab and Cry1Ac combination could be an effective approach to control C. partellus. Furthermore, we show it first time that possible reason behind increase in toxicity of synergistic Cry1A proteins is an increase in toxin binding.

Isolation and characterization of a green tissue-specific promoter from pigeonpea [Cajanus cajan (L.) Millsp.]

Expression of rbcS genes encoding small subunit of rubisco, most abundant protein in green tissue, is regulated by at least three parameters--tissue type, light conditions and stage of development. One of the green tissue-specific promoters of rbcS gene family was isolated from pigeonpea by PCR. Expression of uidA gene encoding beta-glucuronidase in the transgenic tobacco plants under the control of pigeonpea rbcS promoter, clearly showed that this promoter was as strong as pea rbcS3A promoter characterized earlier. Study of the sequence similarity with pea rbcS3A promoter, especially the region (boxes I and III) that is required for rbcS3A expression, showed more than 50% divergence. In contrast, pigeonpea promoter sequence isolated in the present study was more similar to that of spinach and rice rbcS promoters.

Genotoxicity evaluation of polluted ground water in human peripheral blood lymphocytes using the comet assay

This paper presents the genotoxicity experiments with the ground water collected from an area under the influence of textile dyeing and bleaching industries in Tirupur, Tamilnadu, India. The alkaline single cell gel electrophoresis (SCGE) assay was performed in vitro with human peripheral blood lymphocytes. The cells were exposed to two doses of non-volatile organic agents extracted from ground water samples. Ground water samples were collected from 12 locations distributed in and around Tirupur and extracts were taken at different pHs (without pH adjustment and acidic pH 2.0). The persistence of the DNA damage after exposure to the organic extracts was also studied. All the samples were found to contain substances capable of inducing DNA damage in human lymphocytes. Extracts from acidified waters (pH=2.0) were found to induce more DNA damage than extracts from without pH adjustment (natural pH). The DNA damage was not fully repaired after incubation for 2h at 37 degrees C. The chemical characterization of the sub-fractions revealed the existence of aromatic amines in the extracts, which may be responsible for the DNA damaging activity of the water samples. The results of this investigation demonstrate the application of the comet assay in environmental monitoring studies.

Characterization of genetic diversity of some serovars of Bacillus thuringiensis by RAPD

RAPD based fingerprinting of 21 serovars of Bacillus thuringiensis (Bt) representing different serotypes was performed using 19 random decamer primers. A total of 172 polymorphic fragments, ranging in size from 161-2789 bp, were amplified from 13 of the 19 primers. Pairwise genetic similarity analysis revealed very low similarity values, ranging from 3-68%, among the serovars of Bt, indicating high genetic divergence. Nineteen serovars of Bt fell in two major clusters and remaining two formed solitary clusters in the dendogram. Clustering of Bt strains established genetic relatedness between serovars and serotypes. It has been suggested that RAPD analysis can be used for genotypic characterization of Bt to complement flagellar serotyping.