ALK-Positive Anaplastic Large Cell Lymphoma Associated With Hemophagocytic Lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) has been rarely reported as a complication of anaplastic large cell lymphoma (ALCL), especially in the adult population. We herein present a case of a young woman who presented with multiorgan failure and disseminated intravascular hemolysis and was later found to have ALCL-associated HLH. We also review the current literature on ALCL-associated HLH in adult patients, with their respective treatments and outcomes. We discuss the challenges associated with the diagnosis of lymphoma in the setting of HLH and multiorgan failure. Further, given its high mortality rates, we highlight the importance of promptly identifying and treating the underlying etiology of HLH.

Carcinoma En Cuirasse: A Rare but Striking Cutaneous Manifestation of Metastatic Breast Cancer

Carcinoma en cuirasse is a rare cutaneous metastatic presentation of breast cancer with a poor prognosis. We report a female in her 70s with a prior history of left breast ductal carcinoma in situ status post-radiation and lumpectomy who presented with skin thickening of the left breast and a few solid masses in bilateral breasts. Biopsy showed invasive ductal carcinoma of the left breast (estrogen receptor [ER]/progesterone receptor positive [PR], human epidermal growth factor receptor-2 [HER2] negative) and ductal carcinoma in situ of the right breast (ER/PR positive). She underwent a right breast lumpectomy; however, the left breast mastectomy was aborted due to the worsening of her skin findings on preoperative examination. A skin biopsy revealed poorly differentiated invasive ductal carcinoma. She was diagnosed with stage 4 breast cancer, specifically carcinoma en cuirasse. Systemic treatment was initiated, followed by a left breast mastectomy. A surgical biopsy was HER2-positive, and therefore anti-HER2 therapy was given. She remains on maintenance therapy with an excellent response at present.Any unexplained skin findings in breast cancer patients should prompt consideration of carcinoma en cuirasse. With ongoing treatment advances, many newer therapy options are available for metastatic breast cancer. Based on our case, we think that patients with this disease can have better outcomes.

Hepatotoxicity After CDK 4/6 Inhibitor Initiation in the Treatment of Hormone-Positive Metastatic Breast Cancer

Cancer cells proliferate using various mechanisms. One mechanism of preventing tumor cell growth is blockade of the cyclin-dependent kinase (CDK) 4/6 axis. Multiple CDK 4/6 inhibitors - ribociclib, palbociclib, and abemaciclib - have significantly improved progression-free survival rates. However, they can cause hepatotoxicity. We present a case of a 67-year-old female who was diagnosed with stage 1C invasive ductal carcinoma. She was treated with letrozole and ribociclib due to recurrence as metastatic disease, but within 10 days, she developed transaminitis. She then started palbociclib but experienced elevated transaminases within two weeks, needing discontinuation of palbociclib. Subsequent positron-emission tomography/computed tomography imaging showed disease progression, and she was started on fulvestrant. We considered adding abemaciclib, but the patient declined and has had stable disease for more than a year on fulvestrant. CDK 4/6 inhibitors are used to treat metastatic breast cancer and are generally well tolerated. The most common side effect is neutropenia; however, our patient developed transaminitis. The novelty of our case is the development of hepatotoxicity even after the introduction of another CDK 4/6 inhibitor, indicating at least some degree of class effect. In summary, CDK 4/6 inhibitors have significantly improved outcomes in hormone-positive metastatic breast cancers. However, a small percentage suffer from hepatic injury enough to warrant discontinuation of the drug, and we must continue to assess the risk versus benefit profile when offering them to our patients.

A Rare Presentation of Concomitant Lung Disease and Hepatitis After Rituximab Treatment: A Case Report

Rituximab (RTX) is a chimeric monoclonal antibody that is a standard component of treatment for all B-cell malignancies. The most common adverse events related to RTX are infusion-related reactions, such as fever, chills, urticaria, flushing, and headaches. However, RTX-induced lung disease (RTX-ILD) is a rare but potentially fatal adverse reaction, and diagnosing RTX-ILD is challenging, especially when accompanied by other rare adverse reactions, such as hepatitis. Here, we report a case of RTX-ILD with concomitant RTX-induced hepatitis in a 55-year-old man with follicular B-cell non-Hodgkin lymphoma who was on maintenance RTX therapy. The patient presented with a subacute, persistent dry cough, shortness of breath, fevers, and chills shortly after having traveled. Outpatient antibiotic therapy did not relieve symptoms, and laboratory studies revealed evidence of liver injury. A computed tomography (CT) of the chest showed predominately basilar airspace disease and ground glass opacities suggestive of multifocal pneumonia. Extensive infectious and autoimmune workups were negative. RTX-ILD with concomitant RTX-induced hepatitis was considered because antibiotic therapy did not resolve symptoms or improve signs of liver damage. Prednisone (1 mg/kg) led to symptom resolution and liver enzyme improvement. The patient underwent a 30-day steroid taper and the withholding of RTX infusions. A CT of the chest three months after discharge showed nearly resolved multifocal ground glass opacities. RTX-ILD should be considered after infectious and autoimmune etiologies have been ruled out for all patients on RTX therapy who experience symptoms of lung pathology or infection.

Abstract P4-07-35: Changes in Left Ventricular Global Longitudinal Strain in breast cancer patients receiving anti-HER2 and/or Adriamycin therapy and outcomes with early implementation of cardio-protective measures

Background: The treatment of Human Epidermal Growth Factor -2 (HER2) positive breast cancer has advanced since Trastuzumab and subsequently Pertuzumab were introduced and approved as antibody-targeted therapy. With the incorporation of anti-HER2 therapy, cardiotoxicity poses a significant risk and is a well know side effect. This toxicity can increase with concomitant use of Anthracyclines. Left Ventricular Global Longitudinal Strain is assessed using speckle tracking analysis on 2D echocardiogram and a relative reduction in LV global longitudinal strain (GLS) of 10-15% from baseline appears to have specificity to predict downstream reduction in Left Ventricular Ejection Fraction (LVEF). There is growing use for identification of GLS changes in these patients and its incorporation into medical decision making that impacts oncological and cardiac care. Methods: We conducted an analysis of 200 patients receiving anti-HER2 therapy at Henry Ford Cancer institute from Jan 1, 2016 to June 1, 2022 to determine if there was a 10-15% reduction in GLS detected prior to a decrease in ejection fraction and if and how these detections resulted in the implementation of cardio protective measures and downstream effects on cancer therapy. Results: There were 198 patients with GLS and LVEF data. 175 patients (88.3%) completed one year of cancer therapy 107/198 patients (54%) had no change in GLS or LVEF. 91/198 patients (45%) had changes in GLS and or LVEF. 41/91 (45%) patients with LVEF decline did not have cardioprotective intervention implemented. Despite this, 34 (83%) of these patients completed cancer treatment. 50/91 (55%) patients did have cardioprotective interventions with 40 (78%) patients from this subgroup completing cancer treatment. 81% of patients with EF decline were able to complete treatment. 50% of patients with EF decline had EF recovery within 6 months of completion of cancer therapy. The odds of LVEF decline were 9.8 times higher for those with GLS decline (OR=9.0, p< 0.001). Patients with LVEF decline were more likely to have cardio preventive intervention (OR=18.8, p< 0.001). Multivariate analysis did not find an association between cardiac risk factors such as hypertension, diabetes mellitus, smoking, obesity and hyperlipidemia with GLS decline. There was no disparity by race. Conclusion: Our study revealed that early changes in GLS and LVEF did not impact the completion of cancer treatment irrespective of implementation of cardioprotective measures.

Citation Format: Hussna E. Abunafeesa, Cortney Mckay, Pin Li, Madhulata Reddy, Vrushali Dabak. Changes in Left Ventricular Global Longitudinal Strain in breast cancer patients receiving anti-HER2 and/or Adriamycin therapy and outcomes with early implementation of cardio-protective measures [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 P4-07-35.

Abstract P2-03-18: Clinical use of Breast Cancer Index for prediction of late breast cancer recurrence and prediction of benefit in extended endocrine therapy: A single institution experience

Background: The decision to extend adjuvant endocrine therapy beyond five years is often individualized. Breast Cancer Index (BCI) (Biotheranostics, Inc.) is a validated multigene-expression tissue-based analytic tool used in early hormone-positive breast cancer to predict the response to extended endocrine therapy, based on the HOXB13/IL17BR ratio (H/I ratio), and prognosis 5-10 years after diagnosis, based on the molecular grade index (MGI) and H/I ratio. It is presumed that if BCI shows a high likelihood of benefit from endocrine therapy (BCI-high), the treating clinician would recommend extended adjuvant endocrine therapy and if the primary prediction shows a low likelihood of benefit (BCI-low), the clinician would recommend discontinuation of therapy; however, this may not always be practiced. The Clinical Treatment Score post-5 years (CTS5) is a validated clinicopathologic tool that provides a calculated risk assessment of late distant recurrence (LDR). Clinicians may use the calculated CTS5 score in deciding whether to extend adjuvant endocrine therapy and forego additional prognostic testing, such as BCI. The aim of the study is to understand how clinicians integrate BCI results into medical decision making and to determine the correlation with CTS5 scores in making the decision to offer extended endocrine therapy. Methods: This is a single institution retrospective study. All patients within Henry Ford Health Systewho had BCI testing ordered, between April 2016 and January 2022, were included. Recommendations regarding extended endocrine therapy were collected. CTS5 scores were calculated based on patient’s age, tumor size, tumor grade, and number of involved lymph nodes. If available, the 21-gene recurrence scores (Oncotype-DX) and Ki-67 scores were collected for additional comparison. Results: A total of 165 female patients were included in this study. The average age at diagnosis was 58.5 ± 10.4 years old; 116 (70%) were Caucasian, 35 (21%) were African American; 132 patients (80%) were post-menopausal. The decision regarding extending endocrine therapy was concordant with BCI predictive results in 93.3% of patients; endocrine therapy was continued in 87% of patients in the BCI-high group and discontinued in 95% of patients in the BCI-low group (p< 0.001). In comparing the categorical results of BCI predictive scores (low vs. high) and the CTS5 results (low vs. intermediate vs. high) univariate analysis did not detect a statistically significant relationship. In comparing BCI prognostic LDR risk percentage with the CTS5 LDR (5–10 year) risk percentage, a statistically significant, but weak, positive correlation was observed (Pearson correlation coefficient of 0.38487, p-value= < 0.0001). The odds of a BCI-high primary prediction were 1.031 (95% CI: 1.005, 1.057) times higher for every-one percentage increase in Ki-67 (p-value=0.0172), 1.052 (95% CI: 1.003, 1.057) times higher for every one-unit increase in Oncotype-DX score (p-value=0.0353) and 1.232 (95% CI: 124, 1.351) times higher for every-one percentage increase in BCI prognostic LDR risk assessment (p-value < 0.0001). No statistically significant association was found between the BCI predictive score and age, race, stage, lymph node involvement, and HER2 receptor positivity. Conclusions: This single-institution study revealed that clinicians make decisions regarding extended endocrine therapy that are usually concordant with BCI predictive results. CTS5 results weakly correlate with BCI prognostic results but may not provide conclusive information to support a clinical decision. For patients with early hormone-receptor positive breast cancer the BCI tissue-based analysis may influence a decision regarding extending endocrine therapy.

Citation Format: Rebecca Chacko, Manasi M. Godbole, Kylie Springer, Haythem Ali, Vrushali Dabak. Clinical use of Breast Cancer Index for prediction of late breast cancer recurrence and prediction of benefit in extended endocrine therapy: A single institution experience [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 P2-03-18.

Abstract P3-05-05: Racial disparities among patients with breast cancer receiving neoadjuvant chemotherapy therapy and impact on pathologic response: An urban, single-institution experience

Background: Neoadjuvant systemic therapy (NAT) is typically administered to patients diagnosed with non-metastatic invasive breast cancer (IBC) with high-risk features. The goal of NAT in this setting is a pathologic complete response (pCR), meaning no residual invasive disease observed on final review of surgical pathology. It is broadly accepted that pCR may be used as a surrogate marker of predicted long term benefit of treatment and overall survival. Prior studies have demonstrated that the time interval between a diagnosis and initiating NAT may impact the overall outcome for patients.

In this study we sought to determine if there were any differences between African American (AA) patients and other races with respect to time-to-treatment (TTT) in initiating NAT. In addition, we explored the relationship between TTT and pCR rates and the factors influencing this relationship.

Methods: This is a single-institution retrospective study, all patients diagnosed with non-metastatic IBC who were treated with NAT and completed definitive surgery between 2015-2021 were included. Demographic and clinicopathologic details were abstracted from the electronic medical record. Data was analyzed in aggregate; subgroup analysis was completed according to race and histopathologic subtype of breast cancer.

Results: A total of 392 female patients were included in this study: 59.2% White, 35.7% AA, 5.1% were of other races. The average age at the time of diagnosis was 54.1 ± 13.4 years old for the total population, and 54.0 ± 13.0 years old for AA patients. Mean TTT was 33.4 (SD = 18.7) days for all patients, 37.0 (SD = 21.3) days for AA patients and 31.3 (SD = 16.9) days for White patients. A significant difference was identified in AA patients versus the total population (p=0.017), and particularly AA versus White patients (p=0.005). A pCR was achieved in 40.7% of AA patients and 34.7% in the total population (p=0.050). Multivariate analysis of the factors impacting the pCR rate showed that TTT, age, tumor grade and histologic subtype independently influenced the pCR rate. However, race was not an independent factor. Among the studied factors influencing pCR rate only TTT is modifiable (Table 1).

Conclusion: The results of our study show that although AA patients achieve pCR at higher rates than the general population, they do experience delays in TTT which is an independent factor influencing pCR rates. Other factors inherently play a role in achieving a pCR, however, race is not one of them. pCR rates among AA patients may be further improved by reducing TTT and maximizing the potential benefit of neoadjuvant systemic therapy.

Table 1: Association between TTT, race, pCR. Table 1 depicts the demographic distribution related to the mean time-to-treatment (TTT), total population and percentage of Black patients. Data was analyzed as an aggregate and subgroup analyses were conducted according to histologic subtypes. Multivariate analyses were used to explore the association between TTT and pathologic complete response (pCR). HR+=Estrogen/progesterone receptor positive; HER2+= human epidermal growth factor receptor 2 (HER2) present by IHC 3+ score or FISH ≥2 ratio; TNC=triple negative cancer. Indicates a statistically significant finding (i.e.: p=<0.05).

Citation Format: Rebecca Chacko, Nayef Hikmat Abdel-Razeq, Kathren Shango, Pin Li, Vrushali Dabak, Haythem Ali. Racial disparities among patients with breast cancer receiving neoadjuvant chemotherapy therapy and impact on pathologic response: An urban, single-institution experience [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 P3-05-05.

Images in Immunotherapy and Precision Oncology: Angiosarcoma of the Spleen and Liver

Primary splenic or hepatic angiosarcomas are ultra-rare and aggressive malignancies associated with poor prognosis. The mainstay treatments are surgical resection and chemotherapy. We report a case of angiosarcoma in a 50-year-old woman who presented with bruising, fatigue, ecchymosis, and hepatosplenomegaly. She was treated with the multi-kinase inhibitor sunitinib for 4 weeks before developing a splenic hemorrhage and succumbing. Recent studies have demonstrated the clinical benefit of immunotherapies in angiosarcomas. Additionally, sequencing techniques have showcased the diverse molecular aberrations involved in angiosarcomas, which offer opportunities for precision-matched targeted therapies such as inhibitors of the VEGF/VEGFR axis and PI3K/Akt/mTor pathway.

Complete Neurologic Recovery of Cerebral Fat Embolism Syndrome in Sickle Cell Disease

Sickle cell disease is one of the most common inherited hemoglobinopathies diagnosed in the United States. Patients often present with severe anemia, pain crises, infections, and vaso-occlusive phenomena. Complications of these disorders can lead to significant debilitating morbidity and mortality. Fat embolism syndrome (FES) is a rare and devastating complication of sickle cell disease. It usually presents with a rapidly deteriorating clinical course, and the prognosis is dismal. We report a case of FES in a 19-year-old African American male with a history of sickle cell disease who presented with tonic-clonic seizures and was found to have multi-organ failure. FES was diagnosed 20 days from a presentation based on blood cytopenias and magnetic resonance imaging findings that were obscured at the initial presentation. We describe in this report, the patient’s course from presentation until diagnosis and resolution. Our case is peculiar as the patient had a very good outcome without the need for red blood cell (RBC) exchange; instead, supportive treatment and simple RBC transfusions were enough to change the clinical course of this almost fatal syndrome.

Unusual Presentation of T-cell Large Granular Lymphocytic Leukemia

Large granular lymphocytic (LGL) leukemia is a rare chronic lymphoproliferative disorder that can arise from T- or natural killer-cell lineages. It is an indolent disease that typically occurs in the sixth decade of life. Most cases of T-cell LGL leukemia (T-LGL) are associated with autoimmune disorders. Patients with T-LGL are generally asymptomatic; however, they can present with symptoms related to neutropenia, infections, and autoimmune disorders. Here, we report two cases of T-LGL in which the patients presented with liver dysfunction.

Clinical outcomes of COVID-19 in patients with sickle cell disease and sickle cell trait: A critical appraisal of the literature

Individuals with sickle cell disease (SCD) and sickle cell trait (SCT) have many risk factors that could make them more susceptible to COVID-19 critical illness and death compared to the general population. With a growing body of literature in this field, a comprehensive review is needed. We reviewed 71 COVID-19-related studies conducted in 15 countries and published between January 1, 2020, and October 15, 2021, including a combined total of over 2000 patients with SCD and nearly 2000 patients with SCT. Adults with SCD typically have a mild to moderate COVID-19 disease course, but also a 2- to 7-fold increased risk of COVID-19-related hospitalization and a 1.2-fold increased risk of COVID-19-related death as compared to adults without SCD, but not compared to controls with similar comorbidities and end-organ damage. There is some evidence that persons with SCT have increased risk of COVID-19-related hospitalization and death although more studies with risk-stratification and properly matched controls are needed to confirm these findings. While the literature suggests that most children with SCD and COVID-19 have mild disease and low risk of death, some children with SCD, especially those with SCD-related comorbidities, are more likely to be hospitalized and require escalated care than children without SCD. However, children with SCD are less likely to experience COVID-19-related severe illness and death compared to adults with or without SCD. SCD-directed therapies such as transfusion and hydroxyurea may be associated with better COVID-19 outcomes, but prospective studies are needed for confirmation. While some studies have reported favorable short-term outcomes for COVID-19 patients with SCD and SCT, the long-term effects of SARS-CoV-2 infection are unknown and may affect individuals with SCD and SCT differently from the general population. Important focus areas for future research should include multi-center studies with larger sample sizes, assessment of hemoglobin genotype and SCD-modifying therapies on COVID-19 outcomes, inclusion of case-matched controls that account for the unique sample characteristics of SCD and SCT populations, and longitudinal assessment of post-COVID-19 symptoms.

A Rare Case of p190 BCR-ABL Chronic Myeloid Leukemia With a Very Good Response to Tyrosine Kinase Inhibitors

The oncoprotein BCR-ABL has distinct fusion proteins generated from the Philadelphia chromosome translocation, depending on the site of the breakpoint on chromosome 22. The p210 is the hallmark of chronic myeloid leukemia. Only 1% - 2% of patients with chronic myeloid leukemia (CML) demonstrate p190 BCR-ABL. Imatinib mesylate, a tyrosine kinase inhibitor (TKI), specifically targets BCR-ABL, which brought a revolutionary era to the treatment of CML. Although the efficacy of imatinib is widely known, resistance to it has become a pressing challenge in the treatment of CML. CML patients harboring atypical e1a2 transcript (referred to as p190 BCR-ABL) show a poor and short-lived response to first-generation TKI therapy. Patients with p190 BCR-ABL CML should be identified as high-risk patients from the beginning to allow the best chance of a deep molecular response. These patients must be closely monitored during TKI therapy and should be treated upfront with a second-generation TKI. We report a case of p190 BCR-ABL CML with a good response to second-generation TKI.

Transient Anti-Phospholipid Antibodies in Two Patients With COVID-19

We report two cases of coronavirus disease 2019 (COVID-19) in patients who developed pulmonary embolism and transient anti-phospholipid antibodies. At the time of presentation with acute pulmonary embolism, both patients had leukocytosis and increased levels of anti-cardiolipin antibodies, which resolved at testing 12 weeks after initial presentation. Studying cases of pulmonary embolism and increased anti-phospholipid antibodies in the context of COVID-19 could be one of the factors for elucidating the possible connection between severe acute respiratory syndrome coronavirus 2 infection, anti-phospholipid antibodies, and thrombosis.

Acute Splenic Sequestration Crisis in Hemoglobin SC Disease: Efficiency of Red Cell Exchange

Acute splenic sequestration crisis (ASSC) is recognized as a serious complication of sickle cell disease in children. ASSC presents with progressive splenic enlargement, transfusion-dependent anemia, and, eventually, circulatory compromise. ASSC is rare in adult patients, thus making its management and outcome in adults not well-defined. The purpose of this article is to describe our experience in managing ASSC in an adult female with hemoglobin (Hb) SC disease. The patient underwent an automated red blood cell (RBC) exchange, thus avoiding a planned splenectomy. To the best of our knowledge, our case is the third report in the literature on the use of RBC exchange in adults with HbSC disease and ASSC. RBC exchange should be considered in adults with HbSC disease with ASSC not responding to simple transfusion; a treatment that could alleviate patients' symptoms and avoid splenectomy complications, especially in young patients.

Primary Pleural Extranodal Marginal Zone Lymphoma Presenting as Bilateral Chylothorax

Here we describe a case of pleural extranodal marginal zone lymphoma presenting as bilateral chylothorax which has not been reported in the literature prior to this. Primary pleural lymphomas are a rare entity most commonly associated with chronic infections, autoimmune conditions or long-standing pyothorax which were not seen in this case. Chylous pleural effusions in this patient were successfully managed with chemotherapy for the underlying lymphoma.

Impact of COVID-19 Infection on 24 Patients with Sickle Cell Disease. One Center Urban Experience, Detroit, MI, USA

The city of Detroit has a large population of individuals with sickle cell disease, and hospitals in Detroit have seen some of the highest numbers of cases of coronavirus disease-19 (COVID-19) in 2020. The purpose of this study was to examine the pathophysiological characteristics of COVID-19 in patients with sickle cell disease or trait to determine whether these patients have unique manifestations that might require special consideration. This retrospective analysis included 24 patients with confirmed COVID-19 and sickle cell disease or trait who were seen at the Henry Ford Hospital, Detroit, MI, USA, between March 1 and April 15 2020. Of the 24 patients, 18 (75.0%) had heterozygous sickle cell trait, one (4.0%) was a double heterozygote for Hb S (HBB: c.20A>T)/β⁺-thalassemia (β⁺-thal), four had sickle cell anemia (β^S/β^S) and one (4.0%) had Hb S/Hb C (HBB: c.19G>A) disease. A total of 13 (54.0%) patients required hospitalization. All four patients with sickle cell anemia, developed acute pain crisis. We observed one patient who developed acute pulmonary embolism and no patients developed other sickle cell associated complications. Additionally, three (13.0%) patients required packed red blood cell transfusion without the need of exchange transfusion, and one patient required admission to the intensive care unit (ICU), mechanical ventilation and subsequently died. Patients with sickle cell disease or trait and laboratory-confirmed COVID-19 had a generally mild, or unremarkable, course of disease, with lower chances of intubation, ICU admission and death, but with a slightly longer hospitalization.

Abstract 3353: Four vs six cycles of docetaxel and cyclophosphamide (TC) in early stage triple-negative breast cancer

Background: ABC trials established the use of non-anthracycline containing regimen, docetaxel and cyclophosphamide (TC) in the adjuvant setting in early stage breast cancer. In clinical practice, TC is commonly used in Stage I Triple-Negative Breast Cancer (TNBC). However, no specific recommendations exist in literature, regarding the number of cycles that can be used. i.e. TC4 vs TC6. Our aim, was to determine if TC4 is non-inferior to TC6 when used as adjuvant therapy in early stage TNBC.

Methods: We retrospectively reviewed 77 patients who were diagnosed with early stage TNBC between 2007 to 2017, at our institution who had received either TC4 or TC6 as adjuvant therapy. The number of cycles the patients received were based on provider preference. The two groups (TC4, TC6) were compared in regard to stage of cancer at diagnosis based on AJCC 7thedition, grade of adverse events, recurrence and death from breast cancer recurrence.

Results: Out of 77 patients, based on T stage, 25 (32.5%) were T1b, 38(49.4%) were T1c, 13(16.9%) were T2 and 1(1.3%) was T3. All patients were node negative. 53(68.8%) received TC4 and 24(31.2%) received TC6. Regarding side effects, adverse of any grade were seen in 42(79.2%) patients who received TC4 and 23(95.8%) in patients who received TC6(p=0.091). Adverse events which were grade 3 or higher were seen in 7(15.9%) in TC4 group and 3(13%) in the TC6 group (p=1.000). Recurrence in the TC4 group was seen in 4 patients (7.5%) and 3(12.5%) patient in the TC6 group (p=0.259). Death due to breast cancer recurrence was seen in 1 patient (1.9%) in the TC4 group and 1(4.1%) patient in the TC6 group.

Conclusions: In this limited series, TC4 appears to be equally effective to TC6, with fewer adverse events of any grade. However, a longer follow up and a larger patient base is required to be studied for a more definitive conclusion.

Citation Format: Aparna Basu, Hadi A. Mohammed, Sharmeen Mahmood, Vrushali Dabak, Randa Loutfi. Four vs six cycles of docetaxel and cyclophosphamide (TC) in early stage triple-negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3353.

A rare case of follicular lymphoma transformed to a high-grade B-cell lymphoma in orbit

Transformation of lymphoma is an infrequent phenomenon, and involvement of the eye as such is even uncommon. Histological transformation in patients with follicular lymphoma who were previously treated with immune-chemotherapy carry a poor outcome. Here, we illustrate such a case with aggressive histological transformation from a low-grade lymphoma.

Utilization of the 21-Gene Recurrence Score in a Diverse Breast Cancer Patient Population: Development of a Clinicopathologic Model to Predict High-Risk Scores and Response to Neoadjuvant Chemotherapy

INTRODUCTION

The 21-gene expression profile [Oncotype DX Recurrence Score (RS)] stratifies benefit from adjuvant chemotherapy in hormone receptor (HR)-positive, HER2/neu-negative, node-negative breast cancer. It is not routinely applied to predict neoadjuvant chemotherapy (NACT) response; data in diverse patient populations also are limited. We developed a statistical model based on standard clinicopathologic features to identify high-risk cases (RS > 30) and then evaluated ability of predicted high RS to predict for NACT downstaging.

METHODS

Primary surgery patients with Oncotype DX RS testing 2012-2016 were identified from a prospectively-maintained database. A RS predictive model was created and applied to a dataset of comparable NACT patients. Response was defined as tumor size decrease ≥ 1 cm.

RESULTS

Of 394 primary surgery patients-60.4% white American; 31.0% African American-RS distribution was similar for both groups. No single feature reliably identified high RS patients; however, a model accounting for age, HR expression, proliferative index (MIB1/Ki67), histology, and tumor size was generated, with receiver operator area under the curve 0.909. Fifty-six NACT patients were identified (25 African American). Of 21 cases with all relevant clinicopathology, 14 responded to NACT and the model generated high-risk RS in 14 (100%); conversely, of 16 cases generating high-risk RS, only 2 did not respond.

CONCLUSIONS

Predictive modelling can identify high RS patients; this model also can identify patients likely to experience primary tumor downstaging with NACT. Until this model is validated in other datasets, we recommend that Oncotype-eligible patients undergo primary surgery with decisions regarding chemotherapy made in the adjuvant setting.

Idiopathic erythrocytosis in dialysis patients: a case report and literature review

Anemia is a common complication in end-stage renal disease (ESRD) patients. On the other hand, idiopathic erythrocytosis is extremely rare, with only a few cases reported in the literature. We present a case of erythrocytosis that developed after initiating hemodialysis. A 68-year-old male with a history of ESRD secondary to diabetes presented with erythrocytosis that started a few months after initiating dialysis in the absence of having received erythropoietin-stimulating agents or iron supplements. His erythropoietin level was elevated, with a negative JAK2 mutation. Blood gases showed normal oxygen and CO(2), with slightly elevated carboxyhemoglobin. Tiny foci in both kidneys were noted, representing vascular calcifications or renolithiasis. There was no radiological evidence of neoplasms or cysts. After excluding secondary causes, a diagnosis of idiopathic erythrocytosis was made. The patient underwent intermittent phlebotomies during dialysis, and his hemoglobin went from 18.5 to 14 mg/dl. Erythrocytosis in ESRD patients is very rare. So far, there is no complete understanding of the underlying pathophysiology; however, there seem to be multiple possible reasons for an increased erythropoietin level. Phlebotomy is a successful and easy way to control erythrocytosis in such patients. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, currently being used in posttransplant erythrocytosis, might also be considered.

Thrombosis in VonWillebrand disease

OBJECTIVE

To date, only a few case studies have reported occurrence of thrombosis in patients with VonWillebrand disease (VWD). No studies have looked at its incidence in this patient population. The aim of this study was to test our hypothesis that decreased VonWillebrand factor (VWF) levels confer a protective effect on arterial and venous thrombosis.

METHODS

This is a retrospective cohort study including patients (n=350) with the ICD-9 code of VWD who were identified from our hospital database over a period of 25 years, out of which 198 patients were included in the final sample. A parallel control sample without VWD matched for age, sex, hypertension, hyperlipidemia, atrial fibrillation and diabetes mellitus was also obtained from the hospital database. The primary outcomes were incidence of diagnosis of symptomatic arterial and venous thrombosis. The results were computed using multivariate conditional logistic regression analysis and proportions were compared using McNemer's Chi - square test.

RESULTS

Out of 198 patients (mean age 44.2 ± 17.5, women 72%) with VWD, 170 (86%) were VWD type 1, 21 (10%) were type 2 and 7 (3%) were type 3. VWD was found to be an independent protective predictor from arterial thrombosis (OR 0.28, 95% CI 0.14-0.54, p<0.0001), more so in CAD (OR 0.28, 95% CI 0.12-0.64, p=0.002) than in CVD (OR 0.28, 95% CI 0.10-0.77, p=0.01). However this was not the case in venous thrombosis (p=0.42).

CONCLUSION

In a population of relatively younger individuals with VWD, our study suggests a reduced incidence of arterial thrombosis but not of venous thrombosis. This brings up the possibility that there could be other pathways or factors involved in arterial and venous thrombosis. To our knowledge, this is the first large observational study that has provided insight into the thrombotic disease in this group of patients.

A pilot study of thalidomide in recurrent GI bleeding due to angiodysplasias

Angiodysplasias are a major cause of lower gastrointestinal bleeding in patients over the age of 60 years. Although multiple treatment modalities, both medical and surgical, are being used, there is no effective treatment option currently available. Our study defines the use of a novel drug that might be effective against bleeding from vascular malformations. Three patients with a diagnosis of angiodysplasia, who were transfusion dependent, were placed on the study drug. The need for blood transfusions was recorded over the study period and for 6 months after the end of the study. We saw a decreased need for transfusions within 12 weeks of starting the treatment in two patients, and they continued to remain free of transfusion requirement during the immediate follow-up period. The study drug was well tolerated. Thalidomide, with its antiangiogenic mechanism of action, seems to be a promising drug in bleeding angiodysplasias as a treatment option for patients unable to benefit from other available modalities of treatment.

Preferential migration of effector CD8+ T cells into the interstitium of the normal lung

The respiratory tract is a primary site of infection and exposure to environmental antigens and an important site of memory T cell localization. We analyzed the migration and retention of naive and activated CD8+ T cells within the noninflamed lungs and quantitated the partitioning of adoptively transferred T cells between the pulmonary vascular and interstitial compartments. Activated but not naive T cells were retained within the lungs for a prolonged period. Effector CD8+ T cells preferentially egressed from the pulmonary vascular compartment into the noninflamed pulmonary interstitium. T cell retention within the lung vasculature was leukocyte function antigen-1 dependent, while the egress of effector T cells from the vascular to the interstitium functions through a pertussis toxin-sensitive (PTX-sensitive) mechanism driven in part by constitutive CC chemokine ligand 5 expression in the lungs. These results document a novel mechanism of adhesion receptor- and pulmonary chemokine-dependent regulation of the migration of activated CD8+ T cells into an important nonlymphoid peripheral site (i.e., the normal/noninflamed lung).

LFA-1 is required for retention of effector CD8 T cells in mouse lungs

The adhesion molecules involved in the migration and retention of activated effector CD8 T cells in the lung microcirculation and their recruitment into lung tissue are largely unknown. Here, we have analyzed the role of lymphocyte function-associated antigen-1 (LFA-1) and very late antigen-4 (VLA-4) on adhesion of influenza hemagglutinin (HA)-specific CD8 T-cell clone D4 under shear conditions in an in vitro binding assay and in an in vivo homing assay to the lungs of naive or transgenic Balb/c mice expressing HA (HA-Tg) by a lung-specific promoter. Blocking LFA-1 or intercellular adhesion molecule 1 (ICAM-1) significantly inhibited adhesion of D4 cells to lung vascular endothelium and parenchyma of lung sections. However, blocking VLA-4 or vascular cell adhesion molecule 1 (VCAM-1) had no effect on cell adhesion. Blocking LFA-1 in vivo significantly delayed lethal injury following adoptive transfer of D4 cells into HA-Tg mice as assessed by weight loss and histology. Residence time of adoptively transferred Indium 111 (111In)-labeled D4 cells in lungs of normal and HA-Tg mice as analyzed by dual modality imaging revealed a significantly shorter transit time of 4 hours for the D4 cells upon in vivo blockade of LFA-1. These results demonstrate a crucial role for LFA-1 in retention of activated CD8 T cells in normal mouse lungs and in the progression of lethal injury in HA-Tg mice.