Associations of pre-diagnosis physical activity with treatment tolerance and treatment efficacy in breast cancer patients with neoadjuvant chemotherapy

PURPOSE

Higher pre-diagnosis physical activity (PA) is associated with lower all-cause mortality in breast cancer (BCa) patients. However, the association with pathological complete response (pCR) is unclear. We investigated the association between pre-diagnosis PA level and chemotherapy completion, dose delay, and pCR in BCa patients receiving neoadjuvant chemotherapy (NACT).

METHODS

180 stage I-III BCa patients receiving NACT (mean [SD] age of diagnosis: 60.8 [8.8] years) in the Sister Study were included. Self-reported recreational and total PA levels were converted to metabolic equivalent of task-hours per week (MET-hrs/wk). The pCR was defined as no invasive or in situ residual in breast or lymph node (ypT0 ypN0). Multivariable logistic regression analyses estimated odds ratios (ORs) and 95% confidence intervals (CIs) for treatment outcomes.

RESULTS

In this sample, 45 (25.0%) BCa patients achieved pCR. Higher pre-diagnosis recreational PA was not associated with lower likelihood of chemotherapy completion (highest vs. lowest tertile: OR = 0.87, 95% CI = 0.30-2.56; Ptrend = 0.84), greater dose delay (OR = 1.45, 95% CI = 0.54-3.92; Ptrend = 0.46), or greater odds of pCR (OR = 1.28, 95% CI = 0.49-3.34; Ptrend = 0.44). Associations were similar for pre-diagnosis total PA. Meeting the recommended level of recreational PA was not associated with pCR overall (≥ 7.5 vs. < 7.5 MET-hrs/wk: OR = 1.33, 95% CI = 0.59-3.01).

CONCLUSIONS

Although small sample size and limited information on exercise closer to time of diagnosis limit interpretation, pre-diagnosis PA was not convincingly associated with treatment tolerance or treatment efficacy in BCa patients receiving NACT. Future investigations are needed to better understand the impact of pre-diagnosis PA on BCa treatment.

Association between pre-diagnosis recreational physical activity and risk of breast cancer recurrence: the California Teachers Study

PURPOSE

Studies have reported inverse associations of pre-diagnosis recreational physical activity (RPA) level with all-cause and breast cancer (BCa)-specific mortality among BCa patients. However, the association between pre-diagnosis RPA level and BCa recurrence is unclear. We investigated the association between pre-diagnosis RPA level and risk of BCa recurrence in the California Teachers Study (CTS).

METHODS

Stage I-IIIb BCa survivors (n = 6,479) were followed with median of 7.4 years, and 474 BCa recurrence cases were identified. Long-term (from high school to age at baseline questionnaire, or, age 55 years, whichever was younger) and baseline (past 3 years reported at baseline questionnaire) pre-diagnosis RPA levels were converted to metabolic equivalent of task-hours per week (MET-hrs/wk). Multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of BCa recurrence overall and by estrogen receptor (ER)/progesterone receptor (PR) status.

RESULTS

Long-term RPA was not associated with BCa recurrence risk (ptrend = 0.99). The inverse association between baseline pre-diagnosis RPA level and BCa recurrence risk was marginally significant (≥26.0 vs. <3.4 MET-hrs/wk: HR = 0.79, 95% CI = 0.60-1.03; ptrend = 0.07). However, the association became non-significant after adjusting for post-diagnosis RPA (ptrend = 0.65). An inverse association between baseline pre-diagnosis RPA level and BCa recurrence risk was observed in ER-PR- cases (≥26.0 vs. <3.4 MET-hrs/wk: HR = 0.31, 95% CI = 0.13-0.72; ptrend = 0.04), but not in ER+ or PR+ cases (ptrend = 0.97).

CONCLUSIONS

Our data indicates that the benefit of baseline RPA on BCa recurrence may differ by tumor characteristics. This information may be particularly important for populations at higher risk of ER-PR- BCa.

The promise and challenges of multi-cancer early detection assays for reducing cancer disparities

Since improvements in cancer screening, diagnosis, and therapeutics, cancer disparities have existed. Marginalized populations (e.g., racial and ethnic minorities, sexual and gender minorities, lower-income individuals, those living in rural areas, and persons living with disabilities) have worse cancer-related outcomes. Early detection of cancer substantially improves outcomes, yet uptake of recommended cancer screenings varies widely. Multi-cancer early detection (MCED) tests use biomarkers in the blood to detect two or more cancers in a single assay. These assays show potential for population screening for some cancers-including those disproportionally affecting marginalized communities. MCEDs may also reduce access barriers to early detection, a primary factor in cancer-related outcome disparities. However, for the promise of MCEDs to be realized, during their development and testing, we are obligated to be cautious to design them in a way that reduces the myriad of structural, systematic, and personal barriers contributing to disparities. Further, they must not create new barriers. Population studies and clinical trials should include diverse populations, and tests must work equally well in all populations. The tests must be affordable. It is critical that we establish trust within marginalized communities, the healthcare system, and the MCED tests themselves. Tests should be expected to have high specificity, as a positive MCED finding will trigger additional, oftentimes invasive and expensive, imaging or other diagnosis tests and/or biopsies. Finally, there should be a way to help all individuals with a positive test to navigate the system for follow-up diagnostics and treatment, if warranted, that is accessible to all.

Integrating primary care, shared decision making, and community engagement to facilitate equitable access to multi-cancer early detection clinical trials

Effective implementation of cancer screening programs can reduce disease-specific incidence and mortality. Screening is currently recommended for breast, cervical, colorectal and lung cancer. However, initial and repeat adherence to screening tests in accordance with current guidelines is sub-optimal, with the lowest rates observed in historically underserved groups. If used in concert with recommended cancer screening tests, new biospecimen-based multi-cancer early detection (MCED) tests could help to identify more cancers that may be amendable to effective treatment. Clinical trials designed to assess the safety and efficacy of MCED tests to assess their potential for reducing cancer mortality are needed and many are underway. In the conduct of MCED test trials, it is crucial that participant recruitment efforts successfully engage participants from diverse populations experiencing cancer disparities. Strategic partnerships involving health systems, clinical practices, and communities can increase the reach of MCED trial recruitment efforts among populations experiencing disparities. This goal can be achieved by developing health system-based learning communities that build understanding of and trust in biomedical research; and by applying innovative methods for identifying eligible trial patients, educating potential participants about research trials, and engaging eligible individuals in shared decision making (SDM) about trial participation. This article describes how a developing consortium of health systems has used this approach to encourage the uptake of cancer screening in a wide range of populations and how such a strategy can facilitate the enrollment of persons from diverse patient and community populations in MCED trials.

Associations Between Leisure-Time Physical Activity Level and Peripheral Immune Cell Populations in the US General Population, Analysis of the National Health and Nutrition Examination Survey Data, 1999-2018

BACKGROUND

Chronic levels of inflammation are associated with higher risk of many chronic diseases. Physical activity (PA) lowers the risk of cancer, cardiovascular disease (CVD), diabetes and others. One mechanism for PA-induced protection may be through the immune system. We investigated the association between leisure-time PA and peripheral immune cell populations in a large nationally representative sample of the US general population.

METHODS

A total of 17,093 participants [mean (SE) age of 41.6 (0.3) years] of the National Health and Nutrition Examination Survey 1999-2018 were included. Self-reported leisure-time PA was converted to metabolic equivalent of task hours per week (MET-hrs/wk). White blood cell (WBC) count, WBC ratios, and platelet count were derived. Multivariable linear regression analyses were used to estimate associations between leisure-time PA level and peripheral immune cell populations. Multivariable logistic regression analyses were used to estimate associations between leisure-time PA and metrics of WBC count and neutrophil-to-lymphocyte ratio (NLR) which may predict mortality.

RESULTS

A higher leisure-time PA level was associated with a lower WBC count (> 14.0 vs. < 1.2 MET-hrs/wk adjusted mean (95% confidence interval [CI]): 7.12 (6.86, 7.38) vs. 7.38 (7.12, 7.64) 1000 cells/μL, Ptrend < 0.001) and a lower NLR (> 14.0 vs. < 1.2 MET-hrs/wk adjusted mean (95% CI) 2.04 (1.90, 2.18) vs. 2.13 (1.99, 2.28), Ptrend = 0.007). Leisure-time PA level was not associated with lymphocyte-to-monocyte ratio (LMR; Ptrend = 0.25) or platelet-to-lymphocyte ratio (PLR; Ptrend = 0.69). Compared to the lowest leisure-time PA level (< 1.2 MET-hrs/wk), the highest leisure-time PA level (≥ 14.0 MET-hrs/wk) was associated with a lower probability of a high WBC count (> 8.1 × 109 cells/L; odds ratio [OR] = 0.76, 95% CI = 0.66-0.88) and high NLR (> 2.68; OR = 0.84, 95% CI = 0.72-0.99), which may predict CVD and all-cause mortality. The highest leisure-time PA level also linked to a lower probability of a high WBC count (≥ 8.3 × 109 cells/L; OR = 0.76, 95% CI = 0.66-0.88), which may predict cancer mortality.

CONCLUSIONS

We observed an inverse association between leisure-time PA level, WBC count, and NLR, particularly for neutrophil levels. These results suggest that participants at higher levels of leisure-time PA may have lower levels of inflammation, which may be important for future chronic disease outcomes.

Clinicopathological characteristics and treatment outcomes of oesophageal cancer patients in Uganda

Background

Oesophageal cancer is the seventh most common cancer and the sixth leading cause of cancer death worldwide, and its incidence varies globally. In Uganda, the incidence and trend are on the increase. However, there is a paucity of published data regarding this population's oesophageal cancer clinicopathologic characterisation and treatment outcomes.

Objectives

To study the patients' clinicopathologic characteristics and treatment outcomes of oesophageal cancer over 10 years at the Uganda Cancer Institute.

Methods

Patients' charts with histologically confirmed diagnoses of oesophageal cancer for 2009-2019 were identified. Case information, which included patient demographics, history of alcohol use or smoking, tumour location, histological type, tumour grade, clinical TNM (Tumour, Node, Metastasis) staging treatment exposure and treatment outcomes, was evaluated retrospectively. The median survival time was estimated with the Kaplan-Meier method and the median follow-up period was estimated using the reverse Kaplan-Meier.

Results

1,965 oesophageal cancer patients were identified; 1,380(70.23%) were males and 585(29.77 %) females, their mean age was 60.20 years (±12.66). Most males had a history of both alcohol consumption and smoking 640(46.38%). The lower third of the oesophagus was the most common anatomical location 771(39.24%). The majority had squamous cell carcinoma histological type 1,783(90.74%) followed by adenocarcinomas 182(9.26%) in the distal oesophagus. Poorly differentiated tumour grade 743(37.81%) was predominant. The majority of the patients were in stage IVB, 733(37.30%), and most patients were planned for the best supportive care, 731(37.20%). Radiation alone was offered to 621(31.60%) and feeding gastrostomy to 249(12.70%). Treatment outcomes: at the time of the current analysis, 58.68% had died, 1.48% were alive and 39.84% were lost to follow-up. The median follow-up period was 65 months (IQR:35.83-83.30) with a median survival time of 4.47 months (95% CI: 4.17-4.80).

Conclusion

Treatment outcomes of Ugandan oesophageal cancer patients seeking care are poor as most patients present with advanced disease. There is a significant loss of follow-up after treatment initiation. Therefore, reduction in exposure to known modifiable risk factors, early detection and timely referral for treatment strategies are needed to improve outcomes of these patients in our population. Designing interventions to improve treatment adherence is necessary.

TLE3 Sustains Luminal Breast Cancer Lineage Fidelity to Suppress Metastasis

Breast cancer subtypes and their phenotypes parallel different stages of the mammary epithelial cell developmental hierarchy. Discovering mechanisms that control lineage identity could provide novel avenues for mitigating disease progression. Here we report that the transcriptional corepressor TLE3 is a guardian of luminal cell fate in breast cancer and operates independently of the estrogen receptor. In luminal breast cancer, TLE3 actively repressed the gene-expression signature associated with highly aggressive basal-like breast cancers (BLBC). Moreover, maintenance of the luminal lineage depended on the appropriate localization of TLE3 to its transcriptional targets, a process mediated by interactions with FOXA1. By repressing genes that drive BLBC phenotypes, including SOX9 and TGFβ2, TLE3 prevented the acquisition of a hybrid epithelial-mesenchymal state and reduced metastatic capacity and aggressive cellular behaviors. These results establish TLE3 as an essential transcriptional repressor that sustains the more differentiated and less metastatic nature of luminal breast cancers. Approaches to induce TLE3 expression could promote the acquisition of less aggressive, more treatable disease states to extend patient survival.

SIGNIFICANCE

Transcriptional corepressor TLE3 actively suppresses SOX9 and TGFβ transcriptional programs to sustain the luminal lineage identity of breast cancer cells and to inhibit metastatic progression.

Landscape of mutations in early stage primary cutaneous melanoma: An InterMEL study

It is unclear why some melanomas aggressively metastasize while others remain indolent. Available studies employing multi-omic profiling of melanomas are based on large primary or metastatic tumors. We examine the genomic landscape of early-stage melanomas diagnosed prior to the modern era of immunological treatments. Untreated cases with Stage II/III cutaneous melanoma were identified from institutions throughout the United States, Australia and Spain. FFPE tumor sections were profiled for mutation, methylation and microRNAs. Preliminary results from mutation profiling and clinical pathologic correlates show the distribution of four driver mutation sub-types: 31% BRAF; 18% NRAS; 21% NF1; 26% Triple Wild Type. BRAF mutant tumors had younger age at diagnosis, more associated nevi, more tumor infiltrating lymphocytes, and fewer thick tumors although at generally more advanced stage. NF1 mutant tumors were frequent on the head/neck in older patients with severe solar elastosis, thicker tumors but in earlier stages. Triple Wild Type tumors were predominantly male, frequently on the leg, with more perineural invasion. Mutations in TERT, TP53, CDKN2A and ARID2 were observed often, with TP53 mutations occurring particularly frequently in the NF1 sub-type. The InterMEL study will provide the most extensive multi-omic profiling of early-stage melanoma to date. Initial results demonstrate a nuanced understanding of the mutational and clinicopathological landscape of these early-stage tumors.

Obesity accelerates acute promyelocytic leukemia in mice and reduces sex differences in latency and penetrance

OBJECTIVE

Obesity has emerged as a prominent risk factor for multiple serious disease states, including a variety of cancers, and is increasingly recognized as a primary contributor to preventable cancer risk. However, few studies of leukemia have been conducted in animal models of obesity. This study sought to characterize the impact of obesity, diet, and sex in a murine model of acute promyelocytic leukemia (APL).

METHODS

Male and female C57BL/6J.mCG+/PR mice, genetically predisposed to sporadic APL development, and C57BL/6J (wild type) mice were placed on either a high-fat diet (HFD) or a low-fat diet (LFD) for up to 500 days.

RESULTS

Relative to LFD-fed mice, HFD-fed animals displayed increased disease penetrance and shortened disease latency as indicated by accelerated disease onset. In addition, a diet-responsive sex difference in APL penetrance and incidence was identified, with LFD-fed male animals displaying increased penetrance and shortened latency relative to female counterparts. In contrast, both HFD-fed male and female mice displayed 100% disease penetrance and insignificant differences in disease latency, indicating that the sexual dimorphism was reduced through HFD feeding.

CONCLUSIONS

Obesity and obesogenic diet promote the development of APL in vivo, reducing sexual dimorphisms in disease latency and penetrance.

Abstract 3676: Race-specific methylation profiles and epigenetic age acceleration differentiates estrogen receptor status breast cancer

Breast cancer (BrCa) is the second most common cancer among women in the U.S.. Black women with BrCa, on average, have an earlier age of onset, more aggressive subtypes and experience higher mortality compared with White women. Although the underlying causes remain unknown, genetic and lifetime exposures are hypothesized. Here, we utilize blood-based whole-genome methylation arrays to: (1) discover CpG probes related to BrCa receptor status, (2) identify biological pathways driving BrCa subtype disparities, and (3) quantify epigenetic age acceleration differences by race and receptor status.

DNA methylation levels were generated for 95 blood samples from women diagnosed with BrCa using the Illumina EPIC array. After quality control, M-values for 91 samples and 808,329 methylation probes were evaluated using a modified Student t-test. BrCa estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status were collected from health records. Stratified analyses by race adjusting for age were applied. We calculated the association of age acceleration, based on Horvath’s epigenetic clock, by race and receptor status. Statistical significance, corrected for multiple testing, was defined as a p-valueadj &lt;0.05.

Among the 91 BrCa samples, nearly half were Black women (40.7%) and the overall mean age at diagnosis was 56.5 years ±11.3. The majority of BrCa tumors were ER-, 60.4% (N=55), and HER2-, 76.9% (N=70). Overall, two methylation probes significantly differentiated ER+/- BrCa. The most significant methylated gene was FOXK2 (p-valueadj=0.03, logFC=0.63). The race-stratified analysis identified 188,398 probes for ER+/- and five probes for HER2+/- among White women as marginally significant (p&lt;0.05). Two genes (FAM107B, PRKCZ) for ER+/- BrCa and four genes (ZNF430, TTC27, SEC1 and NOS1AP) for HER2+/- BrCa remained statistically significant after correcting for multiple comparisons (p-valueadj &lt; 0.05; |logFC| &gt;1). The mean age acceleration is estimated as 3.7 years greater for Black women compared to White women. Among White women, the mean age acceleration was 1.9 years greater for ER+ than ER- subtypes, and those HER2- were 2.2 years older than HER2+. Similarly, among Black women the mean age acceleration difference for ER- was 3.2 years greater than ER+, and HER2- was 3.8 years older than HER2+.

Our study confirmed (e.g. FOXK2) and identified several novel methylation sites associated with BrCa subtypes. Furthermore, we demonstrated in our study that epigenetic age acceleration of BrCa varies by race, with Black women biologically aging faster than White women. Although this is a limited sample size, stratified analyses revealed biological age differences by race and receptor status. In-depth pathway analyses and measuring additional samples are underway. Lastly, differential methylation profiles for known risk factors of aggressive tumors will be evaluated.

Citation Format: Yanning Wu, Cheryl L. Thompson, Fredrick R. Schumacher. Race-specific methylation profiles and epigenetic age acceleration differentiates estrogen receptor status breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3676.

Perceived risk of breast cancer and god health locus of control in high risk African American and caucasian women

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Background: African American women are more likely than any other racial groups to present with a later stage of breast cancer. Survival rates among African American women with breast cancer are lower than that of their Caucasian counterparts. Studies have shown that women who believe that they can control their health through their own behavior may be more likely to report a lower perceived risk that women who believe that others (such as God or “powerful others” or chance) control their health outcomes. There is a limited body of literature on the effects of spiritual locus of health control and a patient’s perceived risk of breast cancer. Herein, we studied the association between God Locus of Health Control (GLHC) and perceived risk of breast cancer among 85 women recruited from a high-risk clinic. Methods: Consented participants that agreed to the study were asked to fill out the Patient Reported Outcomes Measurement Information Systems (PROMIS) initiative questionnaire. The PROMIS initiative standardizes measurements of psychosocial research in cancer to address major shortcomings in this field. The questionnaire includes demographic characteristics, perceived risk of breast cancer, and questions regarding spiritual and GLHC. Differences in patient demographics (including race), perceived risk, and multivariate testing was performed. Results: When asked to rank their chances of developing breast cancer in their lifetime, Caucasian participants were statistically more likely to respond with a higher perceived risk than African American participants (p = 0.01). Caucasian participants were more likely to respond with a higher perceived risk score when asked to compare their chances of developing breast cancer to that of the average woman their age (p = < 0.001). Linear regressions correlating perceived risk, degree of GLHC and race did not show any statistical significance. Multivariate analyses only showed race was a statistically significant predictor of any of the perceived risk variables. Our study showed that Caucasian participants were more likely to have a lower GLHC score than their African American counterparts and were more likely to perceive a higher risk of developing breast cancer. GLHC was not statistically significantly associated with any of the 4 perceived risk measures (p > 0.05 for all). Conclusions: Overall, there was not a statistically significant relationship between GLHC scores and perceived risk. Further larger-scale studies will be needed to further characterize these findings.

Training the next generation of translational scientists: The Case Western Reserve University Translational Fellows Program

Background

An important part of biomedical research is the translation of discoveries into clinical or community applications that impact patient health. For a vast majority of clinical applications and sustainable community interventions, a time-tested way to get innovations to patients is through licensing of the technology and commercial development, often through startups. While biomedical scientists and trainees are schooled in discovery research, the processes of commercialization are foreign or intimidating. Further, many trainees will not aspire to a faculty position, and other avenues of advancement are desirable.

Methods

At Case Western Reserve University, we developed and launched a Translational Fellows Program to provide such training for the community, focusing specifically on graduate students and postdoctoral fellows. The goals of this program include familiarizing our trainees with the principles of entrepreneurship, product development, and startups. This is accomplished through study of their laboratory's technology to identify points of translational focus and to increase awareness to potentially move ideas and products toward societal impact. This program leverages much of our existing infrastructure and provides a mechanism for the prioritization of the translation of the technology as well as "release-time" to promote effort.

Results

Launched in summer 2020, our first cohort had 3 of the 12 fellows launching startups based on their technology and submitting an National Institutes of Health Small Business Innovation Research (SBIR) proposal. At least 80% reported increased knowledge and confidence in five of six key translational competencies.

Conclusion

We are now continuing and improving the program and searching for sustainable support to stabilize the program for a long-term productive future.

Descriptive Epidemiology of Women in the Emergency Department With Gonorrhea and Chlamydial Infection in the United States

Demographic characteristics, risk factors, and clinical variables associated with gonorrhea and chlamydial infection in women being treated in emergency departments (EDs) in the United States are incompletely characterized. We used univariable and multivariable regression analyses on 17,411 encounters from women 18 years and older who presented to EDs in northeast Ohio and were tested for gonorrhea or chlamydial infection. There were 1,360 women (7.8%) who had Chlamydia trachomatis infection and 510 (2.9%) who had Neisseria gonorrhoeae infection. Those infected with C. trachomatis or N. gonorrhoeae were younger (23.8 vs. 29.2 years), unmarried (97.7% vs. 90.1%), Black (93.3% vs. 88.0%), infected with Trichomonas vaginalis (39.9% vs. 27.2%), diagnosed with urinary tract infection (15.7% vs. 10.6%), and treated for gonorrhea and chlamydial infection during the ED visit (31.6% vs. 17.4%) (all ps < .001). Women infected with C. trachomatis or N. gonorrhoeae had more urine white blood cells (WBCs) (23.9 vs. 16.4 cells per high-power field [HPF]) and leukocyte esterase (1.2+ vs. 0.8+) on urinalysis. They had more WBCs (18.5 vs. 12.4 cells/HPF) and odds of having T. vaginalis infection (12.8% vs. 8.2%) on vaginal wet preparation (all ps < .001). Women infected with C. trachomatis were more likely to be younger and not Black; they were less likely to be treated for gonorrhea and chlamydial infection in the ED and to have lower levels of urine WBCs, leukocyte esterase, and blood than those infected with N gonorrhoeae (all ps ≤ .05).

Prediction model for gonorrhea, chlamydia, and trichomoniasis in the emergency department

OBJECTIVE

History and physical examination findings can be unreliable for prediction of genitourinary tract infections and differentiation of urinary tract infections from sexually transmitted infections (STIs). The study objective was to develop a prediction tool to more accurately identify patients with STIs.

METHODS

A retrospective review of 64,490 emergency department (ED) encounters between April 18, 2014, and March 7, 2017, where patients age 18 years or older had urinalysis and urine culture or testing for gonorrhea, chlamydia, or trichomonas, was used to develop a prediction model for men and women with Neisseria gonorrhoeae or Chlamydia trachomatis, or both, and for women with Trichomonas vaginalis. The data set was randomly divided into two-thirds discovery and one-third validation. Groups were assigned through a random number generator. Backward step regression modeling was used to identify the best model for each outcome.

RESULTS

With use of age, race, marital status, and findings from vaginal wet preparation (white blood cells [WBCs], clue cells, and yeast) and urinalysis (squamous epithelial cells, protein, leukocyte esterase, and WBCs), the models had areas under the receiver operating characteristic curve of 0.80 for men with N gonorrhoeae or C trachomatis, or both; 0.75 for women with N gonorrhoeae or C trachomatis, or both; and 0.73 for women with T vaginalis.

CONCLUSIONS

The model estimated likelihood of ED patients having STIs was reasonably accurate with a limited number of demographic and laboratory variables. In the absence of point-of-care STI testing, use of a prediction tool for STIs may improve antimicrobial stewardship.

Pleiotropy-guided transcriptome imputation from normal and tumor tissues identifies candidate susceptibility genes for breast and ovarian cancer

Familial, sequencing, and genome-wide association studies (GWASs) and genetic correlation analyses have progressively unraveled the shared or pleiotropic germline genetics of breast and ovarian cancer. In this study, we aimed to leverage this shared germline genetics to improve the power of transcriptome-wide association studies (TWASs) to identify candidate breast cancer and ovarian cancer susceptibility genes. We built gene expression prediction models using the PrediXcan method in 681 breast and 295 ovarian tumors from The Cancer Genome Atlas and 211 breast and 99 ovarian normal tissue samples from the Genotype-Tissue Expression project and integrated these with GWAS meta-analysis data from the Breast Cancer Association Consortium (122,977 cases/105,974 controls) and the Ovarian Cancer Association Consortium (22,406 cases/40,941 controls). The integration was achieved through application of a pleiotropy-guided conditional/conjunction false discovery rate (FDR) approach in the setting of a TWASs. This identified 14 candidate breast cancer susceptibility genes spanning 11 genomic regions and 8 candidate ovarian cancer susceptibility genes spanning 5 genomic regions at conjunction FDR < 0.05 that were >1 Mb away from known breast and/or ovarian cancer susceptibility loci. We also identified 38 candidate breast cancer susceptibility genes and 17 candidate ovarian cancer susceptibility genes at conjunction FDR < 0.05 at known breast and/or ovarian susceptibility loci. The 22 genes identified by our cross-cancer analysis represent promising candidates that further elucidate the role of the transcriptome in mediating germline breast and ovarian cancer risk.

Characteristics and outcomes of patients with multiple myeloma at the Uganda Cancer Institute

PURPOSE

Data on multiple myeloma (MM) in sub-Sahara Africa is scarce. In Uganda, there is a progressively increasing incidence of MM over the years.

METHODS

We performed a retrospective study on 217 patients with MM at the UCI using purposive sampling method. The objectives of the study were to determine the clinical characteristics, treatment outcomes, 5 year overall survival and predictors of survival of patients with MM at the UCI from 01 January 2008 to 31 December 2012.

RESULTS

There were 119 (54.8%) males; the mean(SD) age of the study population at presentation was 59(12.8) years; 183(84.3%) patients presented with bone pain, and 135 (61.9%) had skeletal pathology; 186(85.3%) were HIV negative, and 152(70%) had Durie-Salmon stage III. The median overall survival was 2.5 years, (95% CI, 0.393-0.595); factors significantly associated with worse survival were Durie-Salmon stage III disease, HR=5.9, 95% CI (1.61 - 21.74; P=0.007) and LDH >225 U/L HR=3.3, 95% CI (0.57 - 5.92; P=0.029).

CONCLUSION

Most patients with multiple myeloma at the UCI were diagnosed at a relatively young age, presented with late stage disease and bone pain, and had a shorter survival time. Factors associated with worse survival were Durie-Salmon stage III and LDH >225 U/L.

Risk Factors for Keratinocyte Carcinoma in Recipients of Allogeneic Hematopoietic Cell Transplants

Importance

Allogeneic hematopoietic cell transplant (alloHCT) is known to increase the risk for keratinocyte carcinoma. The extent to which host characteristics, including pigmentary phenotype and UV radiation exposure, contribute is unknown.

Objective

To identify and validate independent risk factors for keratinocyte carcinoma after alloHCT, including those associated with the transplant and the host.

Design, Setting, and Participants

This retrospective cohort study analyzed a consecutive sample of alloHCT recipients from January 1, 2000, to December 31, 2014, at the Mayo Clinic, Rochester, Minnesota (n = 872) and University Hospitals Cleveland Medical Center, Cleveland, Ohio (n = 147). Participants from the Mayo Clinic were randomly allocated (2:1) into discovery (n = 581) and validation (n = 291) cohorts. Time to first keratinocyte carcinoma and information about transplant- and host-associated risk factors were extracted. A multivariate keratinocyte carcinoma risk model was created using a stepwise Cox proportional hazards regression model with P ≤ .05 for entry that incorporated all covariates that were individually statistically significant at α = 0.05 in the discovery cohort. The risk model was first internally validated using the Mayo Clinic validation cohort and then externally validated using the independent cohort of alloHCT recipients at University Hospitals Cleveland Medical Center. Data were analyzed from March 13, 2018, to June 12, 2019.

Exposures

Allogeneic hematopoietic cell transplant.

Main Outcomes and Measures

The primary outcome was time to development of the first cutaneous keratinocyte carcinoma after alloHCT; secondary outcome, time to development of the first individual basal and/or squamous cell carcinoma after alloHCT.

Results

Of the 872 alloHCT recipients identified in the Mayo Clinic cohort (520 men [59.6%]; mean [SD] age, 48.3 [12.6] years), 95 (10.9%) developed keratinocyte carcinoma after alloHCT during 5349 person-years of follow-up. Of the 147 alloHCT recipients in the exernal validation cohort (86 men [58.5%]; mean [SD] age, 47.9 [17.5] years), 18 (12.2%) developed keratinocyte carcinoma after alloHCT in 880 person-years of follow up. Risk factors independently associated with keratinocyte carcinoma after alloHCT included age (hazard ratio [HR] per 10 years, 1.72; 95% CI, 1.21-2.42), chronic lymphocytic leukemia (HR, 2.47; 95% CI, 1.20-5.09), clinically photodamaged skin (HR, 3.47; 95% CI, 1.87-6.41), and history of cutaneous squamous cell carcinoma (HR, 2.60; 95% CI, 1.41-5.91). Harrell concordance statistics were 0.81 (95% CI, 0.72-0.90) and 0.86 (95% CI, 0.74-0.98) for internal and external validation of the keratinocyte carcinoma risk model, respectively.

Conclusions and Relevance

This study found validated independent risk factors for keratinocyte carcinoma after alloHCT that are enriched with host- compared with transplant-associated risk factors. These findings highlight the importance of assessing host-associated risk factors for keratinocyte carcinoma in patients eligible for alloHCT. Future studies should examine whether keratinocyte carcinoma risk stratification before alloHCT may inform long-term surveillance strategies.

Development and Validation of a Prediction Model of Prescription Tranquilizer Misuse Based on a Nationally Representative United States Sample

BACKGROUND

Prescription tranquilizer misuse is a risky behavior associated with fatal drug poisonings. Although various predictors have been examined, there is no published prediction model for tranquilizer misuse. This study develops and internally validates a tranquilizer misuse prediction model based primarily on drug histories of participants in a national cross-sectional survey. Predictors also include psychiatric, behavioral and demographic variables.

METHODS

We analyzed data from 471,097 individuals aged 14-to-29-years in the United States, as sampled by the National Survey of Drug Use and Health, 2004-2018, an annual cross-sectional survey. We encoded 21 predictors with known or likely onset prior to tranquilizer misuse initiation, (e.g., early onset of cannabis use). With this dataset, we trained a neural network and regularized logistic regression model. While the assessment for tranquilizer misuse changed slightly in 2015, by pooling all years of survey data, predictions are robust to this source of variation.

RESULTS

1.44% of the pooled sample, 2004-2018, recently initiated tranquilizer misuse (unweighted estimate). On held-out test data (n = 43,714), logistic regression and the neural network performed equally well, with an area under the receiver operating characteristic curve (AUC) of ∼0.83 on the primary model, containing 12 variables known to occur before tranquilizer misuse.

CONCLUSION

Built for case prediction rather than case detection, this model restricted predictors to those with known timing prior to initiation of tranquilizer misuse. Yet its performance supersedes commonly accepted criteria for clinical prediction models (AUC > 0.80). Future work should incorporate survey analysis weights into the prediction model to minimize possible bias.

Activation of TRPV4 by mechanical, osmotic or pharmaceutical stimulation is anti-inflammatory blocking IL-1β mediated articular cartilage matrix destruction

OBJECTIVE

Cartilage health is maintained in response to a range of mechanical stimuli including compressive, shear and tensile strains and associated alterations in osmolality. The osmotic-sensitive ion channel Transient Receptor Potential Vanilloid 4 (TRPV4) is required for mechanotransduction. Mechanical stimuli inhibit interleukin-1β (IL-1β) mediated inflammatory signalling, however the mechanism is unclear. This study aims to clarify the role of TRPV4 in this response.

DESIGN

TRPV4 activity was modulated glycogen synthase kinase (GSK205 antagonist or GSK1016790 A (GSK101) agonist) in articular chondrocytes and cartilage explants in the presence or absence of IL-1β, mechanical (10% cyclic tensile strain (CTS), 0.33 Hz, 24hrs) or osmotic loading (200mOsm, 24hrs). Nitric oxide (NO), prostaglandin E₂ (PGE₂) and sulphated glycosaminoglycan (sGAG) release and cartilage biomechanics were analysed. Alterations in post-translational tubulin modifications and primary cilia length regulation were examined.

RESULTS

In isolated chondrocytes, mechanical loading inhibited IL-1β mediated NO and PGE₂ release. This response was inhibited by GSK205. Similarly, osmotic loading was anti-inflammatory in cells and explants, this response was abrogated by TRPV4 inhibition. In explants, GSK101 inhibited IL-1β mediated NO release and prevented cartilage degradation and loss of mechanical properties. Upon activation, TRPV4 cilia localisation was increased resulting in histone deacetylase 6 (HDAC6)-dependent modulation of soluble tubulin and altered cilia length regulation.

CONCLUSION

Mechanical, osmotic or pharmaceutical activation of TRPV4 regulates HDAC6-dependent modulation of ciliary tubulin and is anti-inflammatory. This study reveals for the first time, the potential of TRPV4 manipulation as a novel therapeutic mechanism to supress pro-inflammatory signalling and cartilage degradation.

Hospital System Adoption of Magnetic Seeds for Wireless Breast and Lymph Node Localization

BACKGROUND

As an alternative to traditional wire localization, an inducible magnetic seed system can be used to identify and remove nonpalpable breast lesions and axillary lymph nodes intraoperatively. We report the largest single-institution experience of magnetic seed placement for operative localization to date, including feasibility and short-term outcomes.

METHODS

Patients who underwent placement of a magnetic seed in the breast or lymph node were identified from July 2017 to March 2019. Imaging findings, core needle biopsy, surgical pathology results, and type of surgery were collected. Outcomes included procedural complications, magnetic seed and biopsy clip retrieval rates, and need for additional surgery.

RESULTS

A total of 842 magnetic seeds were placed by nine radiologists in 673 patients and retrieved by six surgeons at six operative locations. The majority of breast lesions were malignant (395/659, 59.9%); 136 seeds were placed for lymph node localization. The overall magnetic seed retrieval rate was 98.6%, whereas the biopsy clip retrieval rate was 90.9%. Only six patients (0.7%) experienced a complication from magnetic seed placement. Reexcision was performed in 15.2% of patients with breast cancer; 9.6% of benign/high risk lesions were upgraded to malignancy at surgical excision.

CONCLUSIONS

The magnetic seed technique is safe, effective, and accurate for localization of breast lesions and lymph nodes, and importantly uncouples surgery from the localization procedure. The high magnetic seed retrieval rate and low reexcision rate may reflect the accuracy of magnetic marker placement as a "second chance" localization procedure, especially in cases with biopsy clip migration.

Safety of immediate skin-to-skin contact after vaginal birth in vigorous late preterm neonates - A pilot study

BACKGROUND

To evaluate the safety of immediate skin-to-skin contact (SSC) in vigorous late preterm neonates, where observation under radiant warmer is standard of care, in a prospective, randomized, controlled, and equivalence pilot study.

METHODS

Singletons born vaginally at 35-36 6/7 weeks gestation were randomized to initiate immediate SSC or standard of care with continuous pulse oximeter monitoring for the first hour of life.

RESULTS

Forty-seven dyads were randomized to SSC (n = 21) or radiant warmer (n = 26). Vitals were recorded at designated time intervals to assess tolerance of postnatal transitioning. We found no significant difference in the number of SSC interruptions, pulse oximeter readings, initial glucose level, and rates of hypoglycemia, hypothermia, or NICU admission between the two groups.

CONCLUSIONS

Vigorous late preterm neonates transitioned to immediate SSC without additional risks compared to control counterparts. Large, multicenter, and randomized-control studies need to be conducted to establish standardized guidelines for this practice.

Use of acidified versus non-acidified liquid human milk fortifier in very low birth weight infants: A retrospective comparison of clinical outcomes

BACKGROUND

Use of human milk is recommended for low birth weight (VLBW) infants, but must be safety fortified with sterile liquid fortifiers to be nutritionally sufficient. Due to clinical concern for a high incidence of metabolic acidosis among VLBW infants fed human milk fortified with acidified liquid human milk fortifier (ALHMF), we aimed to retrospectively compare the outcomes of infants fed ALHMF to those fortified with non-acidified liquid HMF (NLHMF).

METHODS

Medical records of VLBW neonates admitted to our institution's neonatal intensive care unit from July 1st, 2013 to June 30th, 2014 were reviewed. 129 patients were included in the study, 61 of which received ALHMF and 68 received NLHMF. Metabolic, nutritional and clinical outcomes, including growth, were compared between the two cohorts.

RESULTS

Of the infants who received ALHMF, 70.5% developed metabolic acidosis compared to only 11.8% in the NLHMF group (p < 0.001). In addition, infants who received NLHMF had a 10% greater growth velocity during the period of fortification (p = 0.01). During the full course of hospitalization, no difference in growth velocity was seen between the groups and greater length gains were found in the ALHMF group.

CONCLUSIONS

The use of human milk fortified with ALHMF was associated with an increased incidence of metabolic acidosis and poorer growth during the period of fortification when compared to NLHMF-fortified feedings. These growth effects were not apparent when the duration of hospitalization was considered, suggesting a need for further study to better characterize the advantages and disadvantages of each fortifier.

Phase II study of eribulin mesylate for treatment of CNS metastases (mets) in metastatic breast cancer (mBC)

e12571

Background: There is no approved drug therapy for CNS mets from mBC. Eribulin mesylate (eribulin) is a microtubule inhibitor approved for treatment of mBC patients (pts) who have received at least 2 prior chemotherapy regimens. Previously reported cases have demonstrated significant CNS responses in mBC pts treated with eribulin. This study evaluates the CNS response in pts with mBC treated with eribulin. Methods: CASE7113 was a prospective phase II single-arm study to evaluate the 12-week CNS progression free survival (12-wk CNS-PFS) of pts with mBC and CNS mets treated with eribulin. 20 pts were to be enrolled to demonstrate a 40% 12-wk CNS-PFS (95% CI, 8.5% - 61.5%). All pts had radiologically confirmed mBC CNS lesions with at least one lesion that did not receive prior radiation or surgical resection. Eribulin was administered at standard dose of 1.4mg/m2 IV on days 1 and 8 of a 21 day-cycle. Pts underwent baseline and 12-week brain MRI. The study was closed due to slow accrual; an analysis of enrolled pts was performed. Results: 9 female pts were enrolled; median age was 56 (32-82) years. 55% and 67% had ER+ and/or PR+ and Her2+ mBC respectfully. 1 pt had triple negative breast cancer (TNBC). Median number of prior therapies was 3 (0-12). The 12-wk CNS-PFS (95% CI) was 88.9% (51.8% - 99.7%), the median PFS (95% CI) was 22.6 (4.3 - 31.9) weeks, the median OS (95% CI) was 15.7 (4.0 - 27.3) months. 4 pts achieved stable disease and 1 pt had a partial response. There were no unexpected toxicities. Conclusions: For mBCa pts with CNS mets, this estimate of 12-wk CNS-PFS suggests activity of eribulin and merits further investigation in this population in the context of clinical trials. Clinical trial information: NCT02581839.

Stage IV melanoma of unknown primary: A population-based study in the United States from 1973 to 2014

BACKGROUND

Melanoma of unknown primary (MUP) is incompletely described on a population level.

OBJECTIVE

We sought to characterize stage IV MUP in a population-based cancer registry.

METHODS

We developed a novel search algorithm to identify cases of stage IV MUP in the Surveillance, Epidemiology, and End Results 18 registries from 1973 to 2014. Cases of stage IV melanoma of known primary (MKP) served as a comparison group. Age-standardized incidence rates, demographic characteristics, adjusted disease-specific survival, and Cox proportional hazard models were calculated for MUP and MKP.

RESULTS

A total of 322 stage IV MUP cases and 12,796 stage IV MKP cases were identified in Surveillance, Epidemiology, and End Results 18 registries from 1973 to 2014. The incidence of stage IV MUP is increasing, particularly for patients younger than 30 years of age. In multivariate analyses, age older than 50 and a lack of surgical treatment were negative prognostic factors for stage IV MUP. Relative survival, but not 5-year adjusted disease-specific survival, was higher for stage IV MUP than for MKP.

LIMITATIONS

Limitations include the retrospective study design and possible misclassification of MUP.

CONCLUSIONS

The incidence of stage IV MUP is increasing, and stage IV MUP shares similar prognostic factors with stage IV MKP, including age and surgical treatment.

No association of reproductive risk factors with breast cancer tumor grade

Histological tumor grade is a well-established marker of breast tumor aggressiveness and prognosis. A number of reproductive factors, including parity and age at first birth, have been shown to be related to breast cancer risk, but few studies have examined the association of these variables with breast cancer aggressiveness. In this study, 813 newly diagnosed breast cancer patients were surveyed for demographic and lifestyle characteristics. Tumor grade and other clinical variables were abstracted from medical records. Multivariate logistic regressions were performed with each reproductive factor as the independent variable of interest. Regressions were also stratified on menopausal status, hormone therapy use, and tumor receptor status. None of the reproductive factors examined including age of first period, number of pregnancies, number of births, and hormone usage was statistically significantly associated with tumor grade. Although more studies are needed to determine whether other factors unexplored in this study are related to tumor aggressiveness, our study indicates that these factors do not predict the aggressiveness of breast cancers.

c-Abl inhibits breast cancer tumorigenesis through reactivation of p53-mediated p21 expression

We previously reported that constitutive c-Abl activity (CST-Abl) abrogates the tumorigenicity of triple-negative breast cancer cells through the combined actions of two cellular events: downregulated matrix metalloproteinase (MMP) and upregulated p21^Waf1/Cip1 expression. We now find decreased c-Abl expression to be significantly associated with diminished relapse-fee survival in breast cancer patients, particularly those exhibiting invasive and basal phenotypes. Moreover, CST-Abl expression enabled 4T1 cells to persist innocuously in the mammary glands of mice, doing so by exhausting their supply of cancer stem cells. Restoring MMP-9 expression and activity in CST-Abl-expressing 4T1 cells failed to rescue their malignant phenotypes; however, rendering these same cells deficient in p21 expression not only delayed their acquisition of senescent phenotypes, but also partially restored their tumorigenicity in mice. Although 4T1 cells lacked detectable expression of p53, those engineered to express CST-Abl exhibited robust production and secretion of TGF-β1 that engendered the reactivated expression of p53. Mechanistically, TGF-β-mediated p53 expression transpired through the combined actions of Smad1/5/8 and Smad2, leading to the dramatic upregulation of p21 and its stimulation of TNBC senescence. Collectively, we identified a novel c-Abl:p53:p21 signaling axis that functions as a powerful suppressor of mammary tumorigenesis and metastatic progression.

Melanoma cases demonstrate increased carrier frequency of phenylketonuria/hyperphenylalanemia mutations

Identifying novel melanoma genetic risk factors informs screening and prevention efforts. Mutations in the phenylalanine hydroxylase gene (the causative gene in phenylketonuria) lead to reduced pigmentation in untreated phenylketonuria patients, and reduced pigmentation is associated with greater melanoma risk. Therefore, we sought to characterize the relationship between phenylketonuria carrier status and melanoma risk. Using National Newborn Screening Reports, we determined the United States phenylketonuria/hyperphenylalanemia carrier frequency in Caucasians to be 1.76%. We examined three publically available melanoma datasets for germline mutations in the phenylalanine hydroxylase gene associated with classic phenylketonuria and/or hyperphenylalanemia. Mutations were identified in 29/814 melanoma patients, with a carrier frequency of 3.56%. There was a twofold enrichment (p-value = 3.4 × 10^-5 ) compared to the Caucasian frequency of hyperphenylalanemia/phenylketonuria carriers. These data demonstrate a novel association between phenylalanine hydroxylase carrier status and melanoma risk. Further, functional investigation is warranted to determine the link between phenylalanine hydroxylase mutations and melanomagenesis.

Transcriptome-wide identification of mRNAs and lincRNAs associated with trastuzumab-resistance in HER2-positive breast cancer

Approximately, 25–30% of early-stage breast tumors are classified at the molecular level as HER2-positive, which is an aggressive subtype of breast cancer. Amplification of the HER2 gene in these tumors results in a substantial increase in HER2 mRNA levels, and consequently, HER2 protein levels. HER2, a transmembrane receptor tyrosine kinase (RTK), is targeted therapeutically by a monoclonal antibody, trastuzumab (Tz), which has dramatically improved the prognosis of HER2-driven breast cancers. However, ~30% of patients develop resistance to trastuzumab and recur; and nearly all patients with advanced disease develop resistance over time and succumb to the disease. Mechanisms of trastuzumab resistance (TzR) are not well understood, although some studies suggest that growth factor signaling through other receptors may be responsible. However, these studies were based on cell culture models of the disease, and thus, it is not known which pathways are driving the resistance in vivo. Using an integrative transcriptomic approach of RNA isolated from trastuzumab-sensitive and trastuzumab-resistant HER2+ tumors, and isogenic cell culture models, we identified a small set of mRNAs and lincRNAs that are associated with trastuzumab-resistance (TzR). Functional analysis of a top candidate gene, S100P, demonstrated that inhibition of S100P results in reversing TzR. Mechanistically, S100P activates the RAS/MEK/MAPK pathway to compensate for HER2 inhibition by trastuzumab. Finally, we demonstrated that the upregulation of S100P appears to be driven by epigenomic changes at the enhancer level. Our current findings should pave the path toward new therapies for breast cancer patients.

Chondrocyte expansion is associated with loss of primary cilia and disrupted hedgehog signalling

Tissue engineering-based therapies targeting cartilage diseases, such as osteoarthritis, require in vitro expansion of articular chondrocytes. A major obstacle for these therapies is the dedifferentiation and loss of phenotype accompanying chondrocyte expansion. Recent studies suggest that manipulation of hedgehog signalling may be used to promote chondrocyte re-differentiation. Hedgehog signalling requires the primary cilium, a microtubule-based signalling compartment, the integrity of which is linked to the cytoskeleton. We tested the hypothesis that alterations in cilia expression occurred as consequence of chondrocyte dedifferentiation and influenced hedgehog responsiveness. In vitro chondrocyte expansion to passage 5 (P5) was associated with increased actin stress fibre formation, dedifferentiation and progressive loss of primary cilia, compared to primary (P0) cells. P5 chondrocytes exhibited ~50 % fewer cilia with a reduced mean length. Cilia loss was associated with disruption of ligand-induced hedgehog signalling, such that P5 chondrocytes did not significantly regulate the expression of hedgehog target genes (GLI1 and PTCH1). This phenomenon could be recapitulated by applying 24 h cyclic tensile strain, which reduced cilia prevalence and length in P0 cells. LiCl treatment rescued cilia loss in P5 cells, partially restoring hedgehog signalling, so that GLI1 expression was significantly increased by Indian hedgehog. This study demonstrated that monolayer expansion disrupted primary cilia structure and hedgehog signalling associated with chondrocyte dedifferentiation. This excluded the possibility to use hedgehog ligands to stimulate re-differentiation without first restoring cilia expression. Furthermore, primary cilia loss during chondrocyte expansion would likely impact other cilia pathways important for cartilage health and tissue engineering, including transforming growth factor (TGF), Wnt and mechanosignalling.

Melanoma subtypes demonstrate distinct PD-L1 expression profiles

PD-L1 expression in the tumor immune microenvironment is recognized as both a prognostic and predictive biomarker in patients with cutaneous melanoma, a finding closely related to its adaptive (IFN-γ-mediated) mechanism of expression. Approximately 35% of cutaneous melanomas express PD-L1, however, the expression patterns, levels, and prevalence in rarer melanoma subtypes are not well described. We performed immunohistochemistry for PD-L1 and CD8 on 200 formalin-fixed paraffin-embedded specimens from patients with acral (n=16), mucosal (n=36), uveal (n=103), and chronic sun-damaged (CSD) (n=45) melanomas (24 lentigo maligna, 13 'mixed' desmoplastic, and 8 'pure' desmoplastic melanomas). CD8+ tumor-infiltrating lymphocyte (TIL) densities were characterized as mild, moderate, or severe, and their geographic association with PD-L1 expression was evaluated. Discrete lymphoid aggregates, the presence of a spindle cell morphology, and the relationship of these features with PD-L1 expression were assessed. PD-L1 expression was observed in 31% of acral melanomas, 44% of mucosal melanomas, 10% of uveal melanomas, and 62% of CSD melanomas (P<0.0001). Compared to our previously characterized cohort of cutaneous melanomas, the proportion of PD-L1(+) tumors was lower in uveal (P=0.0002) and higher in CSD (P=0.0073) melanomas, while PD-L1 expression in the acral and mucosal subtypes was on par. PD-L1 expression in all subtypes correlated with a moderate-severe grade of CD8+ TIL (all, P<0.003), supporting an adaptive mechanism of expression induced during the host antitumor response. The tumor microenvironments observed in CSD melanomas segregated by whether they were the pure desmoplastic subtype, which showed lower levels of PD-L1 expression when compared to other CSD melanomas (P=0.047). The presence of lymphoid aggregates was not associated with the level of PD-L1 expression, while PD-L1(+) cases with spindle cell morphology demonstrated higher levels of PD-L1 than those with a nested phenotype (P<0.0001). Our findings may underpin the reported clinical response rates for anti-PD-1 monotherapy, which vary by subtype.

Understanding age and race disparities in the application of sentinel lymph node biopsy in breast cancer

Sentinel lymph node biopsy (SLNB) is the standard of care for surgical evaluation of early-stage breast cancer and is being employed as a quality metric for accreditation of breast centers. Previous studies report disparities in SLNB receipt. The goal of this study is to determine SLNB rates and explore rationale for non-receipt of SLNB. Patients with early-stage breast cancer diagnosed between 2010 and 2011 were identified from the University Hospitals Case Medical Center tumor registry. Multivariable logistic models were used to identify clinical and demographic risk factors for patients who did not receive SLNB. We performed chart reviews to elucidate reasons for the lack of SLNB. Our total sample was 479 patients; of them 432 (90.2%) received SLNB. On average, patients who received SLNB were younger than those who did not receive SLNB (61 compared to 79 years, respectively). Patients ≥80 years were 96% less likely to receive SLNB compared to patients <65 years (OR 0.04; 95% CI 0.00 to 0.14). There were no differences in SLNB by race, between patients undergoing Medicare or Medicaid and managed care, by surgeon specialty, or across medical centers. Chart review determined that 45/47 patients did not have SLNB, because it was a clinical decision-making; advanced age (>80 years) was cited in 27/47 women. Older women had much lower odds of receiving SLNB; however, non-receipt of SLNB was often due to a clinical reasoning. Our study highlights the importance of clinical reasoning in receiving SLNB, whereas other studies solely employing administrative databases do not.

Comparison of Oncotype DX Recurrence Score by Histologic Types of Breast Carcinoma

CONTEXT

Oncotype DX (ODX) is a widely used commercial assay that estimates the risk of distant recurrence and may predict the benefit of chemotherapy in a subset of breast cancers. Some studies have shown the ability to predict Oncotype DX recurrence score (ODXRS), based on routinely reported pathologic features; however, there are limited data correlating specific histologic type of breast cancer to ODXRS.

OBJECTIVE

To compare ODXRS to specific histologic types of breast cancer.

DESIGN

One hundred eighty-four cases were sent for ODXRS testing and the results were compared with histologic type and grade.

RESULTS

The highest average ODXRS was seen in invasive ductal carcinoma with micropapillary features (29) followed by invasive ductal carcinoma not otherwise specified (mean = 19.4, SD = 11.6), invasive mucinous carcinoma (mean = 17.2, SD = 5.9), invasive lobular carcinoma (mean = 15.7, SD = 7.2), mixed ductal and lobular carcinoma (mean = 14.1, SD = 7.7), tubular carcinoma (10.0), and mixed ductal and mucinous carcinoma (mean = 8.0, SD = 4.2). Most tumors that had a high ODXRS were grade 3 invasive ductal carcinoma, representing 13 of a total of 20 cases (65%). Interestingly, 3 of the 4 cases of pure invasive mucinous carcinoma had an intermediate ODXRS.

CONCLUSIONS

Although the numbers are small, our findings raise further awareness of the significance between histologic type and grade, and RS in breast cancer. In some special histologic types of breast cancer, particularly those considered to follow either an excellent or poor clinical course by histology alone, it is unclear whether the ODXRS results are as meaningful as in carcinomas of no special type. Further investigation with higher numbers and outcome data is needed.

Generation of brain pseudo-CTs using an undersampled, single-acquisition UTE-mDixon pulse sequence and unsupervised clustering

PURPOSE

MR-based pseudo-CT has an important role in MR-based radiation therapy planning and PET attenuation correction. The purpose of this study is to establish a clinically feasible approach, including image acquisition, correction, and CT formation, for pseudo-CT generation of the brain using a single-acquisition, undersampled ultrashort echo time (UTE)-mDixon pulse sequence.

METHODS

Nine patients were recruited for this study. For each patient, a 190-s, undersampled, single acquisition UTE-mDixon sequence of the brain was acquired (TE = 0.1, 1.5, and 2.8 ms). A novel method of retrospective trajectory correction of the free induction decay (FID) signal was performed based on point-spread functions of three external MR markers. Two-point Dixon images were reconstructed using the first and second echo data (TE = 1.5 and 2.8 ms). R2(∗) images (1/T2(∗)) were then estimated and were used to provide bone information. Three image features, i.e., Dixon-fat, Dixon-water, and R2(∗), were used for unsupervised clustering. Five tissue clusters, i.e., air, brain, fat, fluid, and bone, were estimated using the fuzzy c-means (FCM) algorithm. A two-step, automatic tissue-assignment approach was proposed and designed according to the prior information of the given feature space. Pseudo-CTs were generated by a voxelwise linear combination of the membership functions of the FCM. A low-dose CT was acquired for each patient and was used as the gold standard for comparison.

RESULTS

The contrast and sharpness of the FID images were improved after trajectory correction was applied. The mean of the estimated trajectory delay was 0.774 μs (max: 1.350 μs; min: 0.180 μs). The FCM-estimated centroids of different tissue types showed a distinguishable pattern for different tissues, and significant differences were found between the centroid locations of different tissue types. Pseudo-CT can provide additional skull detail and has low bias and absolute error of estimated CT numbers of voxels (-22 ± 29 HU and 130 ± 16 HU) when compared to low-dose CT.

CONCLUSIONS

The MR features generated by the proposed acquisition, correction, and processing methods may provide representative clustering information and could thus be used for clinical pseudo-CT generation.

Prostate Cancer Burden at the Uganda Cancer Institute

Purpose

In Uganda, the incidence of prostate cancer is increasing at a rate of 5.2% annually. Data describing presentation and outcomes for patients with prostate cancer are lacking.

Methods

A retrospective review of medical records for men with histologically confirmed prostate cancer at the Uganda Cancer Institute (UCI) from January 1 to December 17, 2012, was performed.

Results

Our sample included 182 men whose mean age was 69.5 years (standard deviation, 9.0 years). Patients who presented to the UCI had lower urinary tract symptoms (73%; n = 131), bone pain (18%; n = 32), increased prostate-specific antigen (PSA; 3%; n = 5), and other symptoms (6%; n = 11). Median baseline PSA was 91.3 ng/mL (interquartile range, 19.5-311.3 ng/mL), and 51.1% of the patients (n = 92) had a PSA value above 100 ng/mL. Gleason score was 9 or 10 in 66.7% of the patients (n = 120). Ninety percent (n = 136) had stage IV disease, and metastatic sites included bone (73%; n = 102), viscera (21%; n = 29), and lymph nodes (4%; n = 5). Spinal cord compression occurred in 30.9% (n = 55), and 5.6% (n = 10) experienced a fracture. A total of 14.9% (n = 27) underwent prostatectomy, and 17.7% (n = 32) received radiotherapy. Gonadotropin-releasing hormone agonist was given to 45.3% (n = 82), 29.2% (n = 53) received diethylstilbestrol, and 26% (n = 47) underwent orchiectomy. Chemotherapy was administered to 21.6% (n = 39), and 52.5% (n = 95) received bisphosphonates. During the 12 months of study, 23.8% of the men (n = 43) died, and 54.4% (n = 98) were lost to follow-up.

Conclusion

UCI patients commonly present with high PSA, aggressive Gleason scores, and stage IV disease. The primary treatments are hormonal manipulation and chemotherapy. Almost 25% of patients succumb within a year of presentation, and a large number of patients are lost to follow-up.

Detection of Lysyl Oxidase-Like 2 (LOXL2), a Biomarker of Metastasis from Breast Cancers Using Human Blood Samples

Metastasis accounts for 90% of the mortality associated with breast cancer. Upregulated expression of members of the lysyl oxidase (LOX) family of secreted copper amine oxidases catalyzes the crosslinking of collagens and elastin in the extracellular matrix. LOXs are linked to the development and metastatic progression of breast cancers. Accordingly, aberrant expression of LOX-like 2 (LOXL2) is observed in poorly differentiated, high-grade tumors and is predictive of diseases recurrence, and for decreased overall patient survival. Therefore, LOXL2 expression may serve as a biomarker for breast cancer. Mechanistically, hydrogen peroxide is produced as a byproduct of LOXL2 when using an appropriate substrate, lysine. We exploited this chemistry to generate a revolutionary gold-based electrochemical biosensor capable of accurately detecting nanomolar quantities of LOXL2 in mouse blood, and in human blood samples. Two different sources of the blood samples obtained from breast cancer patients were used in this study indicating the applicability of detecting LOXL2 in breast cancers patients. Limited numbers of urine specimens from breast cancer patients were also tested. Collectively, all of these tests show the promise and potential of this biosensor for detecting LOXL2 as a surrogate biomarker of breast cancer. This work is described in WO 052962 A1 (2014).

Differential cerebellar GABAA receptor expression in mice with mutations in CaV2.1 (P/Q-type) calcium channels

Ataxia is the predominant clinical manifestation of cerebellar dysfunction. Mutations in the human CACNA1A gene, encoding the pore-forming α1 subunit of CaV2.1 (P/Q-type) calcium channels, underlie several neurological disorders, including Episodic Ataxia type 2 and Familial Hemiplegic Migraine type 1 (FHM1). Several mouse mutants exist that harbor mutations in the orthologous Cacna1a gene. The spontaneous Cacna1a mutants Rolling Nagoya (tg(rol)), Tottering (tg) and Leaner (tg(ln)) mice exhibit behavioral motor phenotypes, including ataxia. Transgenic knock-in (KI) mouse strains with the human FHM1 R192Q and S218L missense mutations have been generated. R192Q KI mice are non-ataxic, whereas S218L KI mice display a complex behavioral phenotype that includes cerebellar ataxia. Given the dependence of γ-aminobutyric acid type A (GABAA) receptor subunit functioning on localized calcium currents, and the functional link between GABAergic inhibition and ataxia, we hypothesized that cerebellar GABAA receptor expression is differentially affected in Cacna1a mutants and contributes to the ataxic phenotype. Herein we quantified functional GABAA receptors and pharmacologically dissociated cerebellar GABAA receptors in several Cacna1a mutants. We did not identify differences in the expression of GABAA receptor subunits or in the number of functional GABAA receptors in the non-ataxic R192Q KI strain. In contrast, tg(rol) mice had a ∼15% decrease in the number of functional GABAA receptors, whereas S218L KI mice showed a ∼29% increase. Our data suggest that differential changes in cerebellar GABAA receptor expression profile may contribute to the neurological phenotype of cerebellar ataxia and that targeting GABAA receptors might represent a feasible complementary strategy to treat cerebellar ataxia.

Abstract P1-09-10: Impact of radiation on cardiovascular outcomes in breast cancer patients

Background: Radiation therapy is a key component in the treatment of breast cancer. Recent studies have attempted to detail the potential impact that radiation may have on the development of cardiovascular complications in patients with breast cancer. The results of these studies, however, are conflicting regarding the magnitude and clinical significance of the cardiovascular effects with the use of modern radiation techniques. The aim of our study was to examine cardiovascular outcomes in breast cancer patients who received radiation therapy compared to those who did not.

Methods: After IRB approval, all breast cancer patients who received systemic chemotherapy at University Hospitals Case Medical Center between 1998 and 2006 and with known radiation data were included in this retrospective study. A complete patient medical history including risk factors, comorbidities, and tumor and treatment characteristics were obtained from the institutional tumor registry and were confirmed by the medical record. Billing data provided dates of diagnosis for heart failure (HF), coronary artery disease (CAD), and arrhythmia. The patients were divided into three groups: no radiation, right sided radiation, and left sided radiation. The groups were compared to one another and then further subdivided and analyzed based on timing of diagnosis of CAD and HF. Multivariate analyses using a Cox proportional hazards model were conducted for each outcome adjusting for age and comorbidities.

Results: 1277 patients were included in this study with average follow-up of 7.3 years (SD =3.5). CT based planning was used for the majority of the patients. Radiation start dates were not available for 186 patients; these were estimated at 5.5 months after the initiation of chemotherapy. There was no significant difference between groups in the incidences of the cardiovascular outcomes (p&gt;0.05). Further analysis after accounting for timing of diagnosis of CAD and HF showed there was a significantly shorter time to onset of CAD in the left sided radiation group compared to the right sided radiation group; 4.5 years (SD=2.2) compared to 6.5 years (SD=3.6) respectively, p&lt;0.001. However, multivariate analyses were not statistically significant (p=0.47). The onset to HF was shorter in the right sided radiation group compared to the left sided radiation group; 3.5 years (SD 3.1) compared to 4.3 years (SD=3.5) respectively, p&lt;0.001, but again, multivariate analyses were not statistically significant (p=0.43).

Discussion: In our study, we did not find a difference in the incidence of adverse cardiovascular outcomes among patients who did and did not receive radiation, both before and after correcting for timing of diagnosis. We did find a difference in the time to development of these adverse cardiovascular outcomes between the two radiation groups, but no difference was found in either the incidence or time to development when controlled for age and co-morbid conditions. This study suggests that there is little impact of radiation on cardiovascular outcomes using modern techniques that limit radiation exposure. Prospective longitudinal studies focused specifically on cardiac endpoints may be needed to fully understand the cardiovascular impact of radiation.

Citation Format: Angel Qin, Paula Silverman, Janice Lyons, Cheryl L Thompson. Impact of radiation on cardiovascular outcomes in breast cancer patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-10.

Abstract P3-04-07: Androgen receptor expression in triple negative breast cancer

Background: Patients with androgen receptor (AR) positive triple-negative breast cancer (TNBC) may derive a significant benefit from anti-androgen therapy. While AR positivity is often defined by protein expression by immunohistochemistry (IHC), the benefit of anti-androgen therapy in patients who have the Luminal Androgen Receptor (LAR) molecular subtype as defined by genomic profiling is unclear. Our aim was to study the clinical, pathologic and molecular profiles of AR+ tumors by IHC in a diverse set of TNBC.

Methods: Tissue microarrays from two separate, well-annotated institutional cohorts (Case Western Reserve University, Yale University) of early-stage TNBC were evaluated for AR expression by IHC (clone SP107, Ventana Benchmark Ultra). AR positivity was defined as greater than or equal to 10% staining in tumor nuclei. AR expression was correlated with clinical and pathologic features such as age, race, grade, and stage within and between the two cohorts. Gene expression was analyzed with the DASL assay (Illumina) on RNA extracted from formalin-fixed paraffin-embedded material using the Ambion RecoverAll kit (Applied Biosystems AM1975). Pietenpol TNBC molecular subtypes were calculated using the online TNBC type tool. Co-expression of AR with other hormone-related proteins including gross cystic disease fluid protein-15 (GCDFP-15, clone EP1582Y, Ventana Benchmark Ultra) and GATA transcription factor 3 (GATA3, clone L50-823, Bondmax Leica) were also assessed.

Results: Overall, 22% of cases (n=192) were AR+ by IHC. There was no association between AR expression and age, race, grade or stage within or between the two cohorts. Gene expression data was available on 88 tumors with AR staining results and demonstrated that AR positivity by IHC was not exclusive for the TNBC LAR molecular subtype. Three of five (3/5) tumors that were classified and LAR were in fact AR+ by IHC. Tumors that were AR+ by IHC were also identified in the basal-like 2 (BL2), mesenchymal stem-like (MSL), immunomodulatory (IM), and unstable molecular TNBC categories with low frequency. Notably, of cases that were rejected as ER+ by gene expression profiling despite being clinically TNBC, three of five (3/5) were in fact AR+ by IHC. Examination of other hormone-related proteins in a subset of these patients revealed that AR expression was significantly associated with GCDFP-15 expression (p=0.0007) and was borderline significant for GATA3 expression (p=0.068).

Conclusions: AR protein expression levels by IHC were similar in two separate institutional archival cohorts of TNBC and did not correlate with age, race, grade or stage. Comparison of AR IHC data with genomic data suggests that the AR+ phenotype is not unique to LAR subtype of TNBC by gene expression profiling. AR protein expression may be seen in clinically TNBC patients who have a more luminal subtype as evidenced by co-expression of GCDFP-15 and GATA3. Our results suggest that AR staining by IHC may be necessary to capture all patients who may benefit from anti-androgen therapy.

Citation Format: Hannah Gilmore, Vinay Varadan, Nicole Williams, Cheryl L Thompson, Stephanie Kim, Peter Hsu, Kristy Miskimen, Aditi Palkar, Shaveta Vinayak, Robert Lindner, Lyndsay Harris. Androgen receptor expression in triple negative breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-04-07.

Serum levels of retinol-binding protein 4 and risk of colon adenoma

Retinol binding-protein 4 (RBP4), a recently identified adipokine and retinol transporter, has been shown to play a causative role in insulin resistance, an underpinning between obesity and colon neoplasia. Yet, the relationship between RPB4 and cancer, including colon neoplasia is largely unexplored. We carried out a cross-sectional study to determine the risk association between RBP4 and colon adenomas. We determined pre-diagnostic serum levels of RBP4 in 626 patients undergoing screening colonoscopies from January 2006 to March 2007. The cases had statistically significant higher levels of RBP4 than the controls (58.5µg/mL ± 38.2 vs. 51.9µg/mL ± 32.5, p=0.03). Multivariate logistic regression model revealed a statistically significant overall association of RBP4 with risk of colon adenoma (OR = 3.10 for each increment of 35µg/mL, CI = 1.15 – 8.66; p = 0.03). Stratified analysis by the median BMI showed that the risk association was largely limited to those with BMI < 27.8 kg/m². Compared to those in the bottom tertile of RBP4, the ORs for the 2^nd and 3^rd tertiles were 1.84 (CI = 0.89–3.8) and 2.14 (CI = 1.08–4.23) respectively (p for trend = 0.03); there was little evidence for such an association among those with BMI ≥ 27.8 kg/m². This is the first study to show colon adenoma risk association with high circulating levels of RBP4. Further study is merited to investigate the mechanism that underlies the RBP4-colon neoplasia link.