Improved nationwide survival of sarcoma patients with a network of reference centers

BACKGROUND

We investigated the impact of the implementation of a network of reference centers for sarcomas (NETSARC) on the care and survival of sarcoma patients in France since 2010.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDTBs), funded by the French National Cancer Institute (INCa) since 2010. Its aims are to improve the quality of diagnosis and care of sarcoma patients. Patients' characteristics, treatments, and outcomes are collected in a nationwide database. The objective of this analysis was to compare the survival of patients in three periods: 2010-2012 (non-exhaustive), 2013-2015, and 2016-2020.

RESULTS

A total of 43 975 patients with sarcomas, gastrointestinal stromal tumors (GISTs), or connective tissue tumors of intermediate malignancy were included in the NETSARC+ database since 2010 (n = 9266 before 2013, n = 12 274 between 2013 and 2015, n = 22 435 in 2016-2020). Median age was 56 years, 50.5% were women, and 13.2% had metastasis at diagnosis. Overall survival was significantly superior in the period 2016-2020 versus 2013-2015 versus 2010-2012 for the entire population, for patients >18 years of age, and for both metastatic and non-metastatic patients in univariate and multivariate analyses (P < 0.0001). Over the three periods, we observed a significantly improved compliance to clinical practice guidelines (CPGs) nationwide: the proportion of patients biopsied before surgery increased from 62.9% to 72.6%; the percentage of patients presented to NETSARC MDTBs before first surgery increased from 31.7% to 44.4% (P < 0.0001). The proportion of patients with R0 resection on first surgery increased (from 36.1% to 46.6%), while R2 resection rate decreased (from 10.9% to 7.9%), with a better compliance and improvement in NETSARC centers.

CONCLUSIONS

The implementation of the national reference network for sarcoma was associated with an improvement of overall survival and compliance to guidelines nationwide in sarcoma patients. Referral to expert networks for sarcoma patients should be encouraged, though a better compliance to CPGs can still be achieved.

Sclerosing Epithelioid Fibrosarcoma (SEF) versus Low Grade Fibromyxoid Sarcoma (LGFMS): Presentation and outcome in the nationwide NETSARC+ series of 330 patients over 13 years

Sclerosing Epithelioid Fibrosarcoma (SEF) and Low Grade Fibromyxoid Sarcoma (LGFMS) are ultrarare sarcomas sharing common translocations whose natural history are not well known. We report on the nationwide exhaustive series of 330 patients with SEF or LGFMS in NETSARC+ since 2010.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDTB). Since 2010, (i) pathological review has been mandatory for sarcoma,and (ii) tumour/patients' characteristics have been collected in the NETSARC+ nationwide database. The characteristics of patients with SEF and LGFMS and their outcome are compared.

RESULTS

35/73 (48%) and 125/257(49%) of patients with SEF and LGFMS were female. More visceral, bone and trunk primary sites were observed in SEF (p < 0.001). 30% of SEF vs 4% of LGFMS patients had metastasis at diagnosis (p < 0.0001). Median size of the primary tumor was 51 mm (range 10-90) for LGFMS vs 80 (20-320) for SEF (p < 0.001). Median age for LGFMS patients was 12 years younger than that of SEF patients (43 [range 4-98] vs 55 [range 10-91], p < 0.001). Neoadjuvant treatment was more often given to SEF (16% vs 9%, p = 0.05). More patients with LGFMS were operated first in reference centers (51% vs 26%, p < 0.001). The R0 rate on the operative specimen was 41% in LGFMS vs 16% in SEF (p < 0.001). Median event-free survival (EFS) of patients with SEF and LGFMS were 32 vs 136 months (p < 0.0001). The median overall survival (OS) was not reached. Fifty-months OS was 93% vs 81% for LGFMS vs SEF (p = 0.05). Median OS was 77 months after first relapse, similar for SEF and LGFMS. In multivariate analysis, age, tumor size, metastasis at diagnosis were independent prognostic factors for OS in LGFMS.

CONCLUSIONS

Although sharing close molecular alterations, SEF and LGFMS have a different natural history, clinical presentation and outcome, with a higher risk of metastatic relapse in SEF. Survival after relapse is longer than with other sarcomas, and similar for SEF and LGFMS.

Intraoperative motive for incomplete resection in primary retroperitoneal sarcoma

INTRODUCTION

Surgical resection is the current standard of care for retroperitoneal sarcoma (RPS). Recent data suggests that up to 5% of patient have incomplete (R2) resection. The exact reason why patients scheduled for surgery with a curative intent to treat ended up with an R2 resection is largely unknown.

AIM OF THE STUDY

To identify intraoperative findings responsible for incomplete (R2) resection in primary RPS.

METHODS

All records of consecutive patients scheduled for a non-metastatic primary RPS surgery between 1995 and 2020 in a tertiary care sarcoma centre were retrospective analyzed.

RESULTS

Among the 347 patients scheduled for surgery, 13 (3.7%) had an incomplete (R2) resection. The reasons for incomplete surgery were intraoperative finding of vascular involvement of great vessels in 5 patients, previously undetected peritoneal metastases in 5 patients, invasion of contralateral kidney/ureter in 2 patients and the need to preserve both kidneys in 1 patient because of his past medical history. Among these patients, 3 had a laparotomy without resection and 10 had a partial resection (i.e. debulking surgery). Severe postoperative complications occurred in 5 patients. The median length of stay in hospital was 19days. After a median follow-up of 12months, the median survival of patients after incomplete resection was 18months. The 1-y, 5-y and 8-y overall survival (OS) for these patients were 46%, 14%, and 7%, respectively.

CONCLUSION

Incomplete (R2) resection for a primary RPS surgery is rare in specialized sarcoma center. The next steps should be to identify the preoperative criteria that lead to this accurate selection and to define the best practice in front of a peroperative discovery of an unresectable RPS.

LEVEL OF EVIDENCE

III.

Natural history and treatment efficacy in an ambispective case series of NTRK-rearranged mesenchymal tumors

BACKGROUND

Apart for infantile fibrosarcoma (IFS), very little is known about NTRK-rearranged mesenchymal tumors (NMTs). The objective of this study is to describe the distribution, characteristics, natural history, and prognosis of NMT.

PATIENTS AND METHODS

This study was carried out as a translational research program, retrospectively from a cohort of 500 soft tissue sarcoma (STS; excluding IFS) and prospectively both in routine practice and from the RNASARC molecular screening program (N = 188; NCT03375437).

RESULTS

Using RNA-sequencing, NTRK fusion was detected in 16 patient tumors diagnosed as STS: 8 samples of sarcoma with simple genomics (4 NTRK-rearranged spindle cell neoplasm, 3 ALK/ROS wild-type inflammatory myofibroblastic tumor, and 1 quadruple Wild-type gastrointestinal stromal tumor) and 8 samples of sarcomas with complex genomics (dedifferentiated liposarcoma, intimal sarcoma, leiomyosarcoma, undifferentiated pleomorphic sarcoma, high-grade uterine sarcoma, malignant peripheral nerve sheath tumor). Among the eight patients with simple genomics, four were treated with tyrosine receptor kinase inhibitor (TRKi) at different stages of the disease and all benefited from the treatment, including one complete response. Among the eight other patients, six evolved with metastatic spreading and the median metastatic survival was 21.9 months, as classically reported in these tumor types. Two of them received a first-generation TRKi without objective response.

CONCLUSIONS

Our study confirms low frequency and histotype diversity of NTRK fusion in STS. While the activity of TRKi in simple genomics NMT is confirmed, our clinical data encourage subsequent studies focusing on the biological relevance of NTRK fusions in sarcomas with complex genomics together with the efficacy of TRKi in this population.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]

INTRODUCTION

Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations.

OBJECTIVE

The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals.

MATERIAL AND METHODES

This is a national survey conducted by questionnaire in all French maternities.

RESULTS

Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized.

CONCLUSION

A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

Should We Abandon Systematic Pelvic and Paraaortic Lymphadenectomy in Low-Grade Serous Ovarian Cancer?

BACKGROUND

Low-grade serous ovarian carcinoma (LGSOC) is a rare disease that accounts for 5% of all ovarian cancers and requires surgical complete debulking. To date, the prognostic value of pelvic and paraaortic lymphadenectomy remains unclear in this population.

PATIENTS AND METHODS

This retrospective cohort of patients with a diagnosis of LGSOC was registered in the Tumeurs Malignes Rares Gynécologiques national network, between January 2000 and July 2017, at 25 centers. All LGSOC were confirmed after pathological review and operated by primary debulking surgery (PDS) or interval debulking surgery after neoadjuvant chemotherapy (NACT-IDS). Primary endpoints were overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 126 patients were included, 86.1% were stage III/IV, and 74.6% underwent lymph node dissection (LND). According to the Completeness of Cancer Resection (CCR) score, 83.7% had complete resection. Median OS was 130 months, and median PFS was 41 months. Pelvic and paraaortic LND had no significant impact on OS (p = 0.78) or DFS (p = 0.93), and this was confirmed in subgroups (advanced stages FIGO III/IV, CCR score 0/1 or 2/3, and timing of surgery PDS or NACT-IDS). Histological positive paraaortic lymph nodes had a significant negative impact on PFS in the whole population (HR 2.21, 1.18-4.39, p = 0.02) and in the CC0/CC1 population (HR, 2.28, 1.13-4.59, p = 0.02).

CONCLUSIONS

Systematic pelvic and paraaortic LND in patients with LGSOC improved neither overall nor PFS. A prospective trial would be necessary to validate these results but would be difficult to conduct due to the rarity of this disease.

[Prophylactic hysterectomy in Lynch syndrome: Feasibility and outcomes]

OBJECTIVES

Lynch syndrome (LS) is a hereditary predisposition to cancers, first of all, colo-rectal and endometrial cancers in women. Although recommended, gynecologic screening has never proven its benefit. Prophylactic surgery can be considered once the parental project is completed. There are few data regarding the assessment of prophylactic surgery. The objectives of our study were to evaluate the feasibility and morbidity of prophylactic hysterectomy in patients with Lynch syndrome.

METHODS

This is a descriptive retrospective study of consecutive patients with LS undergoing prophylactic hysterectomy at the Georges-Pompidou European Hospital from 2002 to 2016. We collected demographic characteristics, results of preoperative assessment, intra- and postoperative data, final pathologic result as well as postoperative follow-up data.

RESULTS

Forty patients were included in the study, and seventeen women had a history of colon cancer surgery. All hysterectomies were performed by laparoscopy, with two cases of laparoconversion. Two intraoperative complications occurred: serosal small bowel injuries and superficial bladder injury. Two early postoperative complications occurred (a peritonitis on small bowel perforation and a peritonitis on left ureteral injury) and two late complications (vesico-vaginal fistula and adhesive small bowel obstruction). All operative specimens were benign. With a median follow-up of 28 months [5-52], no patient had peritoneal cancer.

CONCLUSIONS

Our study shows that prophylactic hysterectomy in Lynch syndrome should be done with caution. Per and postoperative complication rates appear to be higher than in general population, probably related to a more frequent history of colorectal cancer. However, total hysterectomy with bilateral salpingo-oophorectomy appears to be an effective strategy for preventing gynecological cancers in women with the Lynch syndrome.

Abstract P6-17-25: PAM50 and CGH-array genomic characterization of HER2-equivocal breast cancers defined by the ASCO/CAP2013 recommendations and response to treatment

Background

HER2 breast cancer status determines patients' eligibility for targeted therapy. HER2 level of amplification is associated with a better response to anti-HER2 therapy (Arnould CCR 2007, Singer CCR 2017). Benefit of anti-HER2 therapy for equivocal cases remains debated.

Objectives

We aimed to better characterize HER2-equivocal breast cancers by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) according to 2013 ASCO/CAP guidelines using PAM50 gene expression-based molecular subtyping. We then investigated genome-wide copy number alterations of HER2-equivocal cases, assessing agreement between genomic alterations of the chromosome (chr) 17 and molecular subtypes.

Methods

PAM50 (nCounter assay; Nanostring) was performed on RNA from formalin-fixed paraffin-embedded samples of 40 HER2-equivocal cases. These cases were subsequently analyzed by Agilent 60-mer oligonucleotide microarrays for array-based comparative genomic hybridization (aCGH).

Results

The 40 HER2-equivocal cases were classified as Luminal B in 16 cases (40%), HER2-Enriched in 14 cases (35%), Luminal A in 9 cases (22.5%) and Basal-like in 1 case (2.5%) using PAM50.

By IHC, 34 cases (85%) were ER+, 24 (60%) were also PgR+, 26 (65%) were grade III and 33 (82.5%) showed a high Ki67 &gt; 20%.

Using aCGH, 10 cases (25%) presented chr 17q large copy number gain, 10 (25%) showed segmental copy number gains including HER2, 9 (22.5%) showed HER2 amplification, one (2.5%) showed a large copy number loss and 10 cases (25%) didn't show any copy number alteration of the chr 17.

Out of the 14 PAM50 HER2-Enriched cases, only 5 (35.7%) showed HER2 genomic amplification (Table 1). Four HER2 amplified cases at the genomic level were classified as Luminal B (3 cases, Ki67 &gt; 20%, ER+, PgR- by IHC) or Luminal A (1 case, Ki67&lt;20%, ER+, PgR&gt;10% by IHC) using PAM50, although these luminal B tumors presented strong correlation with the HER2-Enriched centroid. In total, 13 cases (32.5%) were discordant between molecular classification and genomic alteration status of the chr 17.

Among patients with early stage HER2-equivocal breast cancers (n=37), 2 received neo-adjuvant chemotherapy (5.4%), 25 received adjuvant chemotherapy (67.6%) and 2 received adjuvant trastuzumab (5.4%). With a median follow up of 5.8 years (3.8-6.9), one controlateral recurrence (2.7%), four metastatic recurrences (10.8%) and three deaths were observed (8.1%).

Conclusion

Using PAM50, the majority of HER2-equivocal cases were classified as Luminal tumors.

At the genomic level, HER2-equivocal cases harbored mostly chr 17 segmental or large copy number gains. These results emphasized the need of HER2 status genomic determination. In line with the new ASCO 2018 recommendations intending to decrease the number of cases considered as HER2 equivocal, we showed that these tumors were mainly HER2 not amplified, ER positive and grade 3. There is no evidence of benefit of anti-HER2 therapy in these cases.

Table 1Genomic alterations of chromosome 17Basal-likeHER2-EnrichedLuminal ALuminal BTotalHER2 amplified05139Large copy number gain013610Segmental copy number gain153110No alteration032510Large copy number loss00011Total11491640

Citation Format: Borcoman E, Ngo C, Rapinat A, Simaga F, Mariani O, Fuhrmann L, Jeannot E, Laé M, Pierga J-Y, Gentien D, Pierron G, Morel P, Brauer HA, Vincent-Salomon A. PAM50 and CGH-array genomic characterization of HER2-equivocal breast cancers defined by the ASCO/CAP2013 recommendations and response to treatment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-25.

Steroid-Refractory Autoimmune Myocarditis after Pembrolizumab Therapy: Failure of Equine Anti-Thymocyte Globulin to Prevent Heart Failure

While immune checkpoint inhibitors (ICIs) are improving outcomes for many cancers, they can have severe adverse effects. Though cardiac immune-related adverse effects (irAEs) are rare, they have considerable morbidity and mortality. Prior case studies have demonstrated successful treatment of ICI induced autoimmune myocarditis with a variety of immunosuppressive regimens. This case describes steroid-refractory autoimmune myocarditis after treatment with pembrolizumab. Treatment with equine anti-thymocyte globulin, a regimen previously documented to reverse ICI induced autoimmune myocarditis, temporarily improved clinical status and cardiac biomarkers, however eventually failed to prevent progression to heart failure and cardiovascular death. This case highlights the importance of early stress-dose steroids, identifies troponin as a potential marker of treatment response, and underscores the value of collaboration between oncology and cardiology for optimal management.

Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: the GANEA 2 study

PURPOSE

GANEA2 study was designed to assess accuracy and safety of sentinel lymph node (SLN) after neo-adjuvant chemotherapy (NAC) in breast cancer patients.

METHODS

Early breast cancer patients treated with NAC were included. Before NAC, patients with cytologically proven node involvement were allocated into the pN1 group, other patient were allocated into the cN0 group. After NAC, pN1 group patients underwent SLN and axillary lymph node dissection (ALND); cN0 group patients underwent SLN and ALND only in case of mapping failure or SLN involvement. The main endpoint was SLN false negative rate (FNR). Secondary endpoints were predictive factors for remaining positive ALND and survival of patients treated with SLN alone.

RESULTS

From 2010 to 2014, 957 patients were included. Among the 419 patients from the cN0 group treated with SLN alone, one axillary relapse occurred during the follow-up. Among pN1 group patients, with successful mapping, 103 had a negative SLN. The FNR was 11.9% (95% CI 7.3-17.9%). Multivariate analysis showed that residual breast tumor size after NAC ≥ 5 mm and lympho-vascular invasion remained independent predictors for involved ALND. For patients with initially involved node, with negative SLN after NAC, no lympho-vascular invasion and a remaining breast tumor size 5 mm, the risk of a positive ALND is 3.7% regardless the number of SLN removed.

CONCLUSION

In patients with no initial node involvement, negative SLN after NAC allows to safely avoid an ALND. Residual breast tumor and lympho-vascular invasion after NAC allow identifying patients with initially involved node with a low risk of ALND involvement.

[Acquisition of clinical observation skills by medical students improves with discipline-based teaching. The example of neurological examination]

INTRODUCTION

Since 2014-2015, practical teaching of clinical observation skills for 2^nd year medical students at our faculty has been discipline-based; previously, each clinical lecturer had to cover all medical fields. We assessed the impact of this teaching reform on the neurological examination skills of medical students in a before-and-after study.

METHODS

Pre-reform 3^rd and post-reform 2^nd and 3^rd year medical students (n=62, n=71 and 52, respectively) had to perform 7 neurological examination items, for which performance criteria had been pre-defined. Subsequently, we assessed whether the mean grade in neurological examination skills during the test at the end of the 2^nd year was different between students who had received neurological teaching from a neurologist (n=29) or another specialist (n=102).

RESULTS

The median [interquartile range] number of items acquired by post-reform 3^rd year students (4 [2-5]) was higher than that of pre-reform 3^rd year students (2 [1-3]; P<0.001), but lower than that of post-reform 2^nd year students (5 [4-6]; P=0.01). The mean grade obtained during the practical test was not different in students trained by a neurologist or another specialist.

CONCLUSION

Acquisition of neurological examination skills improved after the teaching reform which consisted of: (1) a discipline-based practical teaching of clinical observation skills; (2) a training of clinical lecturers to teach a limited list of educational objectives; and (3) the introduction of a practical test at the end of the 2^nd year of medical studies. However, there was a decline in clinical observation skills between 2^nd and 3^rd year medical students.

Abstract P2-05-11: Not presented

This abstract was not presented at the symposium.

Tocilizumab for the treatment of birdshot uveitis that failed interferon alpha and anti-tumor necrosis factor-alpha therapy: two cases report and literature review

Biotherapies appear as potential drugs for the treatment of inflammatory noninfectious uveitis. In this report, we show that tocilizumab, an anti-IL-6 agent, greatly improved two patients with birdshot chorioretinopathy refractory to conventional immunosuppressive drugs, interferon α2a, and anti-TNFα agents. After a follow-up of 22 months, patients exhibited an improvement of both visual acuity and macular edema. A corticosteroid-sparing effect was achieved in both cases.

Morbidity of rectosigmoid resection in cytoreductive surgery for ovarian cancer. Risk factor analysis

AIM

Rectosigmoid resection is often performed during cytoreductive surgery for ovarian cancer, to achieve the goal of no residual tumour. Here, we evaluated the morbidity associated with rectosigmoid resection and the underlying risk factors.

METHODS

We retrospectively assessed consecutive patients managed with rectosigmoid resection during cytoreductive surgery for ovarian cancer at our centre in Paris, France, between 2005 and 2013. All previously identified risk factors were analysed. Major complications were defined as grade III-IV in the Clavien-Dindo classification.

RESULTS

Of 228 patients, 116 had primary and 112 interval surgery; 43/228 [18.9%]; experienced major complications, and these were more common after primary surgery [24.1% vs. 13.4%, p = .04]. The 69 patients who had rectosigmoid resection [33 primary vs. 36 interval surgery, p = .32] had a higher morbidity rate compared to the other patients [30.4% vs. 14.6%, p = .006]. The anastomotic leakage rate was 2.89%. By multivariate logistic regression, independent risk factors for morbidity were postmenopausal status [adjusted odds ratio (aOR), 13.7; 95% confidence interval (95%CI), 1.2;161.9], surgery after neoadjuvant chemotherapy [aOR, 4.4; 95%CI, 1.1;18.8], and peritoneal stripping of the left; paracolic gutter [aOR, 11.3; 95%CI, 2.3;54.3].

CONCLUSION

The morbidity of rectosigmoid resection during cytoreductive surgery for ovarian cancer seems acceptable. Ileostomy does not seem associated with a lower risk of major complications or adjuvant bevacizumab with a higher complication rate.

Abstract P3-04-09: Genomic analysis to evaluate response to neoadjuvant anastrozole and fulvestrant in post-menopausal ER-positive HER2-negative breast cancer patients included in the UCBG CARMINA02 trial

Background: CARMINA02 is a non-comparative multicenter phase II randomized trial evaluating the clinical response rate after up to 6 months of neoadjuvant endocrine therapy (NET) in HR+/HER2- patients with 1 mg anastrozole (Arm A) or 500 mg fulvestrant (Arm B). Secondary objectives included predictive markers of response and outcome. Between 2007 and 2011, 116 women with operable infiltrating breast adenocarcinoma T2-T4 N0-N3 M0 were randomized. Clinical response rates at 6 months (RECIST criteria) were 52.6% [95%CI 41-64%] in Arm A and 36.8% [95%CI 25-49%] in Arm B (Cancer 2016, in press). We aimed to identify the molecular predictive markers of resistance or sensitivity common to both treatments.

Methods: Ninety tumor RNA from clinical responder (n=34) and resistant patients (n=23) treated in arms A or B have been sequenced with Illumina Hiseq2500 technology leading to 2x100-nt paired-end RNA-seq reads. These samples are from pre-treatment (29 in arm A, 28 in arm B) and post-treatment tumors (6 months after, 17 in arm A and 16 in arm B). Alignment was performed with Tophat_2.0.6. Differential gene expression was analyzed with the Differential Expression analysis for Sequence count data package. Gene fusion was detected with ChimeraScan, TophatFusion and DeFuse tools. Variant calling including variations, insertions and deletions was processed following GATK recommendations for RNAseq datas. Quantitative RT-PCR experiments were done to confirm RNA-seq expression results in patient samples not selected for RNA-seq analysis (validation cohort).

Results: We first analyzed differentially expressed genes (DEGs) between responders and non-responders in pre-treatment or post-treatment samples to select potential predictive markers of response. We identified 51 DEGs before treatment common to anastrozole and fulvestrant. Among these 51 genes, SGK2 was the only gene more intensely expressed in responders than in non-responders. Then we compared DEGs between pre and post-treatment samples for responders or non-reponders for both treatment arms. SGK2 expression remains stable after treatment. Furthermore we identified 7 DEGs specific to responders and 11 DEGs specific to non-responders. Concerning genes fusion detection predicted by at least 2 tools, none was specific to a response type. We noted a higher number of fusions in non-responders samples. Variants detected by RNA-Seq are being confirmed by DNA-Seq using a home-made next-generation sequencing panel including 95 genes frequently mutated in breast cancers (analysis ongoing).

Conclusion:High expression of SGK2, encoding a kinase induced in response to signals that activate PI3kinase, may represent a predictive marker of sensitivity to NET. DEGs associated with NET response or resistance belong to cell cycle, DNA replication and repair, cell death and drug metabolism. Ongoing DNA-seq datas will complete this genomic analysis. This research was conducted with support from AstraZeneca and Institut Curie.

Citation Format: Callens C, Bessoltane N, Ngo C, Chemlali W, Becette V, Bernard V, Delattre O, Lemonnier J, Mouret-Reynier M-A, Andre F, Bieche I, Lerebours F. Genomic analysis to evaluate response to neoadjuvant anastrozole and fulvestrant in post-menopausal ER-positive HER2-negative breast cancer patients included in the UCBG CARMINA02 trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-04-09.

Prediction of axillary lymph node status in male breast carcinoma

BACKGROUND

To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

PATIENTS AND METHODS

From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC.

RESULTS

About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate.

CONCLUSIONS

Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

Meeting the challenge of interpreting high-resolution single nucleotide polymorphism array data in prenatal diagnosis: does increased diagnostic power outweigh the dilemma of rare variants?

OBJECTIVE

Several studies have already shown the superiority of chromosomal microarray analysis (CMA) compared with conventional karyotyping for prenatal investigation of fetal ultrasound abnormality. This study used very high-resolution single nucleotide polymorphism (SNP) arrays to determine the impact on detection rates of all clinical categories of copy number variations (CNVs), and address the issue of interpreting and communicating findings of uncertain or unknown clinical significance, which are to be expected at higher frequency when using very high-resolution CMA.

DESIGN

Prospective validation study.

SETTING

Tertiary clinical genetics centre.

POPULATION

Women referred for further investigation of fetal ultrasound anomaly.

METHODS

We prospectively tested 104 prenatal samples using both conventional karyotyping and high-resolution arrays.

MAIN OUTCOME MEASURES

The detection rates for each clinical category of CNV.

RESULTS

Unequivocal pathogenic CNVs were found in six cases, including one with uniparental disomy (paternal UPD 14). A further four cases had a 'likely pathogenic' finding. Overall, CMA improved the detection of 'pathogenic' and 'likely pathogenic' abnormalities from 2.9% (3/104) to 9.6% (10/104). CNVs of 'unknown' clinical significance that presented interpretational difficulties beyond results from parental investigations were detected in 6.7% (7/104) of samples.

CONCLUSIONS

Increased detection sensitivity appears to be the main benefit of high-resolution CMA. Despite this, in this cohort there was no significant benefit in terms of improving detection of small pathogenic CNVs. A potential disadvantage is the high detection rate of CNVs of 'unknown' clinical significance. These findings emphasise the importance of establishing an evidence-based policy for the interpretation and reporting of CNVs, and the need to provide appropriate pre- and post-test counselling.

Abstract P1-01-19: Prediction of axillary lymph node status in male breast carcinoma

Background: To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

Patients and methods: From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie. We analysed the calibration and discrimination performance of two nomograms (Institut Curie (IC), Memorian Sloan-Kettering Cancer Center (MSKCC)) originally designed to predict axillary lymph node metastases in female BC.

Results: 55% and 24% of the tumours were pT1 and pT4 respectively. 46% demonstrated axillary lymph node metastasis. 99% were estrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (p = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95%CI, 0.54–0.79) and 0.64 (95% CI, 0.52–0.76) respectively. The calibration of these two models was inadequate (Table 1).

Comparison of measurements of time outdoors and light levels as risk factors for myopia in young Singapore children

AIMS

To compare methods to measure time outdoor and light levels, two possible predictors of myopia, in Singapore children.

METHODS

Outdoor time from a diary and portable light meter over a 1-week period was compared in 117 Singapore children aged 6-12 years with and without myopia. All children wore a (HOBO Pendant temp/light Part # UA-002-64) light meter for 1 week and the parents filled the 7-day outdoor diary to track the outdoor activity.

RESULTS

Mean outdoor time from diary and time with light levels was 5.44 hours per week and 7.91 hours per week, respectively, during school term and school holidays. Time spent with light levels of >1000 Lux from the light meter were 7.08 h per week and 9.81 h per week, respectively, during school term and school holidays. The intraclass correlation coefficients were 0.21 and 0.28 for outdoor time from the diary and light meter (1000 Lux cut-off) during the school term and holidays, respectively. The correlation coefficient was 0.34 (95% CI 0.05, 0.58) for a weekday during school holidays, 0.17 (-0.14, 0.45) for a weekday during school term, 0.07 (-0.16, 0.29) for a weekday during school term, and 0.25 (0.02, 0.46) for a weekend during school term.

CONCLUSIONS

The agreement between the light meter and 1-week diary was poor to fair. Both instruments measure different parameters, time outdoors and light intensity, and could therefore capture different aspects of risk in future myopia studies.

Heterogeneous Amplification of HER2 Is a Rare but Clinically Significant Event in Invasive Ductal Carcinoma

BackgroundWe have recently shown that pT1ab HER2 positive tumors carry a poor prognosis, which may be alleviated by trastuzumab (T) based therapy (Rodrigues et al, ASCO 2009). We had also reported that heterogeneous expression of HER2 (hetHER2) may be associated with a poor outcome depending on the HER2 overexpressing subclone (Cottu et al, Ann Oncol 2007). Meanwhile, ASCO/CAP guidelines have questioned the minimum valid score for HER2 expression (Moeder et al, J Clin Oncol 2007; Wolff et al, J Clin Oncol 2007). We describe here the characteristics and outcome of a series of patients with hetHER2 disease.Patients and methodsHER2 status is routinely assessed in our institution in advanced breast cancer patients since 1999, and in early patients since 2002. Out of 1300 HER2 positive cases, we have been able to identify 12 pts with heterogeneous expression of HER2 in the primary tumor (&lt;1%). HetHER2 was defined as more than 5% and less than 59% of infiltrating cells overexpressing HER2 with an intense and complete membrane staining, and /or with a FISH ratio ≥ 2.2. Confirmation was obtained by FISH in 8 patients. Detailed pathological analysis, clinical characteristics and outcome were obtained.ResultsMedian age at diagnosis was 45 years (31-64). All pts received adequate locoregional therapy according to institutional guidelines. Pathological characteristics of the primary tumors are depicted in the table.Pathological Characteristics pT1pT2pT3Tumor Size (n)633 n/ n evaluable%ER+11/1292PR+5/1242HER2 FISH+8/1080vascular emboli5/862.5 pN0pNmi/i+pN+pN (n)624 I / lowII / intermediateIII / highGrade (Elston Ellis)255Mitotic Index327 All patients had infiltrating ductal carcinoma, two of them bearing also a ductal carcinoma in situ component. Most ER+ tumors had a faint staining, observed in less than 50% of tumor cells. In 1 pt with a node-positive tumor, the same pattern of heterogeneous overexpression of EHR2 was observed in the primary tumor and in the lymph nodes. Chemotherapy was given to 9 patients (75%), hormonal treatment to 6 pts (50%) and T was added to chemotherapy in 3 pts. With a median follow-up of 69 months (0-200), 6 pts have relapsed, none of them having received T based therapy. Median time to relapse was 46 mths (14-151). Initial sites of relapses were axillary lymph nodes (1), mediastinal lymph nodes (1), skin (1), liver (2) and ipsilateral relapse (1). No brain metastases were recorded. HER2 status was obtained in four relapses and was considered either negative (Skin), or highly overexpressed (liver) or heterogeneous (ipsilateral and axillary lymph node relapses). None of the 3 T treated pts has relapsed so far, but their follow up is still under 6 months.ConclusionsMore than half of the tumors exhibited at least 1 poor prognosis feature beyond HER2 overexpression. In the line of the recent reanalysis of the NCCTG9831 adjuvant T trial which has suggested that T may be beneficial to hetHER2 patients (Sukov et al, ASCO 2009), our data support the evidence of a poor prognosis of hetHER2 disease, which may be similar to the prognosis of the “real” HER2 3+ and amplified disease. Prospective evaluation of anti HER2 based therapy in this subset of patients is clearly warranted.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6034.

Detection of cryptic pathogenic copy number variations and constitutional loss of heterozygosity using high resolution SNP microarray analysis in 117 patients referred for cytogenetic analysis and impact on clinical practice

BACKGROUND

Microarray genome analysis is realising its promise for improving detection of genetic abnormalities in individuals with mental retardation and congenital abnormality. Copy number variations (CNVs) are now readily detectable using a variety of platforms and a major challenge is the distinction of pathogenic from ubiquitous, benign polymorphic CNVs. The aim of this study was to investigate replacement of time consuming, locus specific testing for specific microdeletion and microduplication syndromes with microarray analysis, which theoretically should detect all known syndromes with CNV aetiologies as well as new ones.

METHODS

Genome wide copy number analysis was performed on 117 patients using Affymetrix 250K microarrays.

RESULTS

434 CNVs (195 losses and 239 gains) were found, including 18 pathogenic CNVs and 9 identified as "potentially pathogenic". Almost all pathogenic CNVs were larger than 500 kb, significantly larger than the median size of all CNVs detected. Segmental regions of loss of heterozygosity larger than 5 Mb were found in 5 patients.

CONCLUSIONS

Genome microarray analysis has improved diagnostic success in this group of patients. Several examples of recently discovered "new syndromes" were found suggesting they are more common than previously suspected and collectively are likely to be a major cause of mental retardation. The findings have several implications for clinical practice. The study revealed the potential to make genetic diagnoses that were not evident in the clinical presentation, with implications for pretest counselling and the consent process. The importance of contributing novel CNVs to high quality databases for genotype-phenotype analysis and review of guidelines for selection of individuals for microarray analysis is emphasised.

First-trimester ultrasound diagnosis of skeletal dysplasia associated with increased nuchal translucency thickness

A series of five cases of skeletal dysplasia is reported in which the diagnosis was reached at the 11-14-week routine ultrasound examination in our referral center. All five cases had increased nuchal translucency thickness (NT) associated with bone abnormalities. We review the current literature on skeletal dysplasia in the first trimester of pregnancy associated with increased NT.

Identification of a haplosufficient 3.6-Mb region in human chromosome 11q14.3-->q21

Cytogenetic deletions are almost always associated with phenotypic abnormality and are very rarely transmitted. We have located a hitherto undescribed, familial deletion involving the region 11q14.3-->q21 in five individuals in a three-generation kindred. Four of the deletion carriers show no phenotypic abnormality; the other, who is the proband, was investigated for short stature and poor academic progress. In view of the apparent innocuous nature of this genetic imbalance, the deletion was investigated in detail to determine its size (3.6 Mb) and location with reference to molecular markers and genetic content. The deleted region is described by a contig of 37 BACS including the flanking regions, which we have assembled. Several possible contributory factors are considered, which might explain the lack of clinical significance of this large deletion. It is notable that there are few genes in this region and none have known functions. All most likely have copies elsewhere in the genome and a number of other hypothetical genes appear to be members of certain gene families, i.e. none is unique. Part of the region (1 Mb) is also duplicated at the pericentromeric region 11p11. Given the very low proportion of the genome occupied by single copy genes and their uneven distribution, regions such as this, which appear to be functionally haplosufficient, may be more common than hitherto recognised.

Perlecan binds to the beta-amyloid proteins (A beta) of Alzheimer's disease, accelerates A beta fibril formation, and maintains A beta fibril stability

Perlecan is a specific heparan sulfate proteoglycan that accumulates in the fibrillar beta-amyloid (A beta) deposits of Alzheimer's disease. Perlecan purified from the Engelbreth-Holm-Swarm tumor was used to define perlecan's interactions with A beta and its effects on A beta fibril formation. Using a solid-phase binding immunoassay, freshly solubilized full-length A beta peptides bound immobilized perlecan at two sites, representing both high-affinity [K(D) = approximately 5.8 x 10(-11) M for A beta (1-40); K(D) = approximately 6.5 x 10(-12) M for A beta (1-42)] and lower-affinity [K(D) = 3.5 x 10(-8) M for A beta (1-40); K(D) = 4.3 x 10(-8) M for A beta (1-42)] interactions. An increase in the binding capacity of A beta (1-40) to perlecan correlated with an increase in A beta amyloid fibril formation during a 1-week incubation period. The high-capacity binding of A beta (1-40) to perlecan was similarly observed using perlecan heparan sulfate glycosaminoglycans and was completely abolished by heparin, but not by chondroitin-4-sulfate. Using a thioflavin T fluorometry assay, perlecan accelerated the rate of A beta (1-40) amyloid fibril formation, causing a significant increase in A beta fibril assembly over a 2-week incubation period at 1 h (2.8-fold increase), 1 day (3.6-fold increase), and 3 days (2.8-fold increase) in comparison with A beta (1-40) alone. Perlecan also initially accelerated the formation of A beta (1-42) fibrils within 1 h and maintained significantly higher levels of A beta (1-42) thioflavin T fluorescence throughout a 2-week experimental period in comparison with A beta (1-42) alone, suggesting perlecan's ability to maintain amyloid fibril stability. Perlecan's effects on A beta (1-40) fibril formation and maintenance of A beta (1-42) fibril stability occurred in a dose-dependent manner and was also mediated primarily by perlecan's glycosaminoglycan chains. Perlecan was the most effective enhancer and accelerator of A beta fibril formation when compared directly with other amyloid plaque components, including apolipoprotein E, alpha1-antichymotrypsin, P component, C1q, and C3. This study, therefore, demonstrates that perlecan not only binds to the predominant isoforms of A beta, but also accelerates A beta fibril formation and stabilizes amyloid fibrils once formed, confirming pivotal roles for perlecan in the pathogenesis of A beta amyloidosis in Alzheimer's disease.

Localization of perlecan (or a perlecan-related macromolecule) to isolated microglia in vitro and to microglia/macrophages following infusion of beta-amyloid protein into rodent hippocampus

The origin of the heparan sulfate proteoglycan (PG), perlecan, in beta-amyloid protein (A beta)-containing amyloid deposits in Alzheimer's disease (AD) brain is not known. In the present investigation we used indirect immunofluorescence, SDS-PAGE, and Western blotting with a specific perlecan core protein antibody to identify possible cell candidates of perlecan production in both primary cell cultures and in a rat infusion model. Double and triple-labeled indirect immunofluorescence was performed on dissociated primary rat septal cultures using antibodies for specific identification of cell types and for perlecan core protein. In mixed cultures of both embryonic day 18 (containing neurons and glia) and postnatal day 2-3 (devoid of neurons), microglia identified by labeling with OX-42 or anti-ED1 were the only cell type also double labeled with an affinity-purified polyclonal antibody against perlecan core protein. Similar immunolabeling of microglia with the anti-perlecan antibody was also observed in purified cultures of post-natal rat microglia. Analyses of PGs from cultured postnatal rat microglia by Western blotting using a polyclonal antibody against perlecan core protein revealed an approximately 400 kDa band in cell layer, which was intensified following heparitinase/heparinase digestion, suggestive of perlecan core protein. Other lower Mr bands were also found implicating either degradation of the 400 kDa core protein or the presence of separate and distinct gene products immunologically related to perlecan. Reverse transcription followed by polymerase chain reaction using human perlecan domain I specific primers demonstrated perlecan mRNA in cultured human microglia derived from postmortem normal aged and AD brain. Following a 1-week continuous infusion of A beta (1-40) into rodent hippocampus, immunoperoxidase immunocytochemistry and double-labeled immunofluorescent studies revealed perlecan accumulation primarily localized to microglia/macrophages within the A beta infusion site. These studies have identified microglia/macrophages as one potential source of perlecan (or a perlecan-related macromolecule) which may be important for the ongoing accumulation of both perlecan and A beta in the amyloid deposits of AD.

Novel purification and detailed characterization of perlecan isolated from the Engelbreth-Holm-Swarm tumor for use in an animal model of fibrillar A beta amyloid persistence in brain

Co-infusion of the specific heparan sulfate proteoglycan (HSPG), perlecan, and beta-amyloid protein (A beta) into rodent hippocampus leads to a consistent animal model to study the effects of fibrillar A beta amyloid in brain [Snow, A.D. et al. (1994) Neuron 12, 219-234]. In the present study, we describe our rapid novel method of perlecan isolation. The isolation method does not require cesium chloride centrifugation and exploits a newly discovered aggregating property of a approximately 220 kDa PG observed during gel filtration chromatography, which allowed it to be affectively separated from non-aggregating perlecan. Fifty or 100 g of EHS tumor were routinely extracted using 4 M guanidine-HCl, followed by anion-exchange and gel filtration chromatography. SDS-PAGE (before and after digestion with heparitinase/heparinase or nitrous acid) followed by staining with silver demonstrated no other contaminating proteins in the perlecan preparations. Western blots using a specific perlecan core protein antibody (HK-102) following heparitinase digestion showed a characteristic doublet at 400 and 360 kDa indicative of intact perlecan core protein. Absence of contamination by other basement membrane components produced by the EHS tumor was confirmed by absence of immunoreactive bands on Western blots using antibodies against laminin, fibronectin, or type IV collagen. One week continuous co-infusion of perlecan obtained from this methodology, with A beta (1-40) into rodent hippocampus, led to deposition of fibrillar A beta amyloid in 100% (10 of 10) of animals. The detailed protocol for isolation and characterization of perlecan from EHS tumor ensures perlecan of the highest quality, and maximizes the potential effects of A beta amyloid deposition/persistence in brain using the animal model. High quality perlecan obtained from this novel isolation method will also allow future studies utilizing in vitro assays to determine the potential interactions of this specific HSPG with other macromolecules.

Antibody Fc functional activity of intravenous immunoglobulin preparations treated with solvent-detergent for virus inactivation

We report here results of in vitro comparisons of the Fc functional activity of a second-generation intravenous immunoglobulin (IGIV) preparation (Venoglobulin-I) and a third-generation IGIV product that includes a deliberate virus-inactivation step (Venoglobulin-S). Both formulations showed equivalent Fc-mediated function against viral antigens (rubella, influenza A, and influenza B) by single-radial hemolysis test, and against group B Streptococcus, Staphylococcus aureus and Escherichia coli by opsonophagocytosis assay. In addition, we showed by three different immunochemical reactions and by HPLC analysis that both preparations consisted of mostly monomeric IgG and contained very low levels of complement-fixing IgG aggregates. However, IgG aggregation induced by heating at 63 degrees C markedly enhanced fixation of Clq and C3 and binding to Raji cells, indicating that the IgG molecules retained their complement-fixing capacity. Thus, the incorporation of a virus inactivation step in the manufacture of our third-generation IGIV did not alter the Fc functional activities of the IgG, as measured by these in vitro assay systems.

Characterization of proteoglycans synthesized by murine embryonal carcinoma cells (P19) reveals increased expression of perlecan (heparan sulfate proteoglycan) during neuronal differentiation

Proteoglycans (PGs) incorporated into cell layer and secreted into media were characterized during retinoic acid-induced neuronal differentiation of cultured P19 murine embryonal carcinoma cells. Heparan sulfate significantly increased (P < 0.01) in cell layer following neuronal differentiation of P19 cells by 3.9-fold. CL-4B gel chromatography revealed the major PGs present in cell layer of stem cells eluted as a broad peak with a Kav = 0.65, and was susceptible to chondroitin ABC lyase. The chondroitin ABC lyase resistant material eluted as a broad peak between Kav = 0.40 and Kav = 0.60, and was only partially digested with heparitinase/heparinase (with resistant material eluting at Kav = 0.70). Therefore, the cell layer of stem cells contained primarily chondroitin sulfate/dermatan sulfate (CS/DS) PGs, with lesser amounts of heparan sulfate proteoglycans (HSPGs). This was confirmed by SDS-PAGE. The CS/DS PGs in the cell layer of stem cells had an apparent M(r) of approximately > 200 kDa, and the HSPGs had an apparent M(r) of approximately 140-230 kDa. In contrast, the major PGs in the cell layer of neurons consisted primarily of HSPGs, with only a minor proportion of CS/DS PGs. Furthermore, both gel filtration chromatography and SDS-PAGE analysis revealed a larger HSPG in the cell layer of neurons (Kav = 0.3-0.6 on CL-4B following chondroitin ABC lyase digestion; M(r) 170 kDa- > 400 kDa on SDS-PAGE) in comparison to stem cells (Kav = 0.4-0.6 on CL-4B following chondroitin ABC lyase digestion; M(r) 140-230 kDa on SDS-PAGE). Likewise, the major PGs secreted into media of stem cells consisted almost exclusively of CS/DS PGs, with lesser amounts of HSPGs, whereas an increase in HSPGs in the media of neurons was apparent. Western, Northern, and immunocytochemical analysis demonstrated that mRNA transcript and protein levels for a specific HSPG (i.e., perlecan) markedly increased in cell layer following P19 neuronal differentiation. Perlecan core protein was identified by Western blot analysis using specific monoclonal and polyclonal antibodies, as a large HSPG with a core protein of apparent M(r) approximately 370-400 kDa, and was observed primarily in extracts from neurons. Northern blot analysis with a cDNA to perlecan revealed a significant (P < 0.01) 12.7-fold increase in expression of perlecan in neurons (day 9) in comparison to stem cells. The increase in perlecan message during P19 neuronal differentiation was concomitant with a significant (P < 0.01) 26.3-fold increase in message for beta-amyloid precursor protein (beta PP).(ABSTRACT TRUNCATED AT 400 WORDS)