Systemic immune mediators reflect tumour-infiltrating lymphocyte intensity and predict therapeutic response in triple-negative breast cancer

Triple-negative breast cancer (TNBC) is an aggressive form of breast cancer (BC). Neoadjuvant chemotherapy has proven efficacy in its treatment, and a pathological complete response (pCR) to therapy is predictive of improved long-term survival. The immune response is key to successful neoadjuvant chemotherapy, as indicated by the relation between the percentage of stromal tumour-infiltrating lymphocytes (TILs) in pre-treated tumour tissue samples and the likelihood of achieving pCR. Here we studied systemic immune mediators from volunteer TNBC patients before undergoing neoadjuvant chemotherapy to determine the systemic response association with TIL intensity, treatment response and survival. Patients were classified into pCR responder or non-responder at time of surgery. We found higher levels of immune mediators before treatment began in patients that went on to be pCR responders versus non-pCR, with area under the curve (AUC) values of 0.64-0.80. We also observed a positive correlation between inflammatory systemic immune mediators and the percentage of TILs in pCR responder patients. Combining TILs and systemic immune mediator levels provided stronger AUC values (range of 0.72-0.82). Last, performing a progression-free survival analysis with several of the systemic cytokines that predict pCR, segregated the patients into long- and short-survival groups based on high and low production of the cytokines, respectively. Our study demonstrates that circulating cytokines, before treatment begins, predict pCR in TNBC patients treated with neoadjuvant chemotherapy. Moreover, they may act as a surrogate marker of high TILs or together with TILs to better predict pCR and survival.

Early postoperative outcomes among patients with delayed surgeries after preoperative positive test for SARS-CoV-2: A case-control study from a single institution

Background

There are limited data on surgical complications for patients that have delayed surgery after severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. We aimed to analyze the surgical outcomes of patients submitted to surgery after recovery from SARS‐CoV‐2 infection.

Methods

Asymptomatic patients that had surgery delayed after preoperative reverse‐transcription polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 were matched in a 1:2 ratio for age, type of surgery and American Society of Anesthesiologists to patients with negative RT‐PCR for SARS‐CoV‐2.

Results

About 1253 patients underwent surgical procedures and were subjected to screening for SARS‐CoV‐2. Forty‐nine cases with a delayed surgery were included in the coronavirus disease (COVID) recovery (COVID‐rec) group and were matched to 98 patients included in the COVID negative (COVID‐neg) group. Overall, 22 (15%) patients had 30‐days postoperative complications, but there was no statistically difference between groups –16.3% for COVID‐rec and 14.3% for COVID‐neg, respectively (odds ratio [OR] 1.17:95% confidence interval [CI] 0.45–3.0; p = .74). Moreover, we did not find difference regarding grades more than or equal to 3 complication rates – 8.2% for COVID‐rec and 6.1% for COVID‐neg (OR 1.36:95%CI 0.36‐5.0; p = .64). There were no pulmonary complications or SARS‐CoV‐2 related infection and no deaths within the 30‐days after surgery.

Conclusions

Our study suggests that patients with delayed elective surgeries due to asymptomatic preoperative positive SARS‐CoV‐2 test are not at higher risk of postoperative complications.

Abstract P2-16-30: Neoadjuvant therapy outcomes in non metastatic invasive breast carcinomas - Results from a large Brazilian cohort

Introduction: Neoadjuvant chemotherapy in addition to increasing the rate of breast conservation, offers a invaluable opportunity to monitor individual tumor response which may be related to survival outcomes. In view of this, neoadjuvant treatment has been increasingly used.However, several distinct strategies and protocols are employed in this scenario, depending on the histological subtype and local preferences, and there is no clear definition of which one is the best. Most of the published series are from developed countries. Here we describe results of neoadjuvant therapy for non metastaic breast cancer treated in a single Brazilian cancer center.Objective: To evaluate the clinical and pathological characteristics and survival outcomes of breast cancer patients treated with neoadjuvant chemotherapy diagnosed in a single specialized Brazilian institution. Method: This is an observational, retrospective cohort, which included patients diagnosed with invasive breast cancer (stage I to III) submitted to neoadjuvant chemotherapy between January 2007 and December 2018.Results: We evaluated 685 patients with a median age of 46 years, 23.9% were younger than 40 years of age, 64.2% were premenopausal, 24% had a mutation in the BRCA1/2 gene and 70% were treated in the private.Regarding staging, 2.2% had stage I disease, 33.9% stage II, and 63.9% stage III. Approximately 95% of patients received anthracycline-containing regimens. Among patients with ERBB2+ tumors, 97.1% received an anthracycline regimen and 30.3% received double anti-HER2 blockade. Eleven percent of patients with triple-negative triple tumors received carboplatin, and only 0.5% of the hormone receptor positive patients received neoadjuvant hormone therapy. Forty percent of the patients demonstrated complete clinical response and only 30% of thenderwent conservative surgery. Thirty-seven percent had complete pathological response (RCB-0), 13.1% had minimal residual disease (RCB-1,) 40% had moderate to extensive residual disease (RCB-2 and RCB-3), and 0, 8% presented disease progression. The RCB-0 rate was 45.7% for AC dense dose and 31.9% AC for conventional dose (p=0.001). Regardless of hormonal status, in the subgroup with ERBB2 + tumors, the rate of RCB-0 was 61% for those who received HER2 double-blockade versus 55.1% for those who received anti-HER2 monotherapy (p=0.049). Nineteen percent of the patients progressed during the follow-up, with 17% having locoregional progression. In the last follow-up, 70% of the patients were alive without disease, with a median cancer-specific survival (CSS) of 133 months. The median CSS was 129 months among luminal tumors, 116 months for triple-positive, 117 months for triple-negative, and 91 months for HER2 super-expressors (p=0.008). The median SCC of the patients that achieved RCB-0 was 116 months, 89 months for those who had RCB-III, and 27 months for those who presented disease progression (p=0.004). CSS was the same for patients who received or not anthracycline and for those who were treated or not with dense dose schedules. Twenty percent of patients with triple-negative tumors received carboplatin, 52% had RCB-0 versus 34% for those who did not receive carboplatin (p=0.002), however, we did not observe any difference in CSS between these groups (p=0.109). Patients with triple-negative tumors were the only ones in which we observed a direct association between achieving RCB-0 and better CSS and progression-free survival (PFS) (p=0.001 for both). Conclusion: The administration of dose-dense anthracycline, of carboplatin and of anti-HER2 double-blockade increased the rate of RCB-0, nevertheless, this did not translate into improved CSS. Achiving complete pathological response in the triple-negative subtype was was associated with improved CSS and PFS.

Citation Format: Monique Celeste Tavares, Marcelle G Cesca, Fernanda A Oliveira, Poliana Andrade, Camilla A Fogassa, Rafaela Pirolli, Bruna R Mattos, Mariana P Xerfan, Sinara Figueiredo, Fernando AB Campos, Vinicius F Calsavara, Solange M Sanches, Fabiana B Makdissi, Cynthia A Bueno, Marina Sonagli, Marina Canal, Vladmir CC Lima. Neoadjuvant therapy outcomes in non metastatic invasive breast carcinomas - Results from a large Brazilian cohort [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-16-30.

Diffusion-Weighted Magnetic Resonance Imaging of Patients with Breast Cancer Following Neoadjuvant Chemotherapy Provides Early Prediction of Pathological Response - A Prospective Study

The purpose of this study was to evaluate the capacity of diffusion-weighted magnetic resonance imaging (DW-MRI) for early prediction of pathological response in breast cancer patients undergoing neoadjuvant chemotherapy (NCT). This prospective unicentric study evaluated 62 patients who underwent NCT. MRI was performed prior to the start of treatment (MR1), after the first NCT cycle (MR2), and upon completion of NCT (MR3). Pathological response was used as the gold-standard. Patients’ median age was 45.5 years and the median tumor size was 40 mm. Twenty-four (38.7%) tumors presented complete pathological response (pCR). The percent increase in apparent diffusion coefficient (ADC) value between MR1 and MR2 was higher in the pCR group (p < 0.001). When the minimum increase in ADC between MR1 and MR2 was set at 25%, sensitivity was 83%, specificity was 84%, positive predictive value was 77%, negative predictive value was 89%, and accuracy was 84% for an early prediction of pCR to NCT. Meanwhile, there were no significant changes in major tumor dimensions between MR1 and MR2. In conclusion, an increase in ADC after the first cycle of NCT correlates well with pCR after the chemotherapy in our cohort, precedes reduction in tumor size on conventional MRI, and may therefore be used as an early predictor of treatment response.

Abstract 2213: Investigation of treatment resistance with DNA-damage agents in patients with triple negative breast cancer by ctDNA

Loss of function (LOF) germline mutation in BRCA1 increases the risk of breast cancer, especially the triple-negative breast cancer (TNBC) subtype, a very aggressive tumor. TNBC exhibits high variability at both molecular and clinical aspects. BRCA impairment is associated to deficiency in homologous recombination repair (HRD) and tumor with HRD has benefit from treatment with drugs that induces DNA damage and also with PARP inhibitor. We previously detected that a significant fraction of TNBC diagnosed in young Brazilian exhibits BRCA1 impairment by both mechanisms - germline pathogenic mutation and promoter hypermethylation - and that this group of tumor presented better overall survival (Brianese et al 2018).

In the current study our aim is to comprehensively characterize the resistance to DNA-damage agents in patients with TNBC associated or not with HRD by investigating somatic mutations in circulating plasma DNA (cDNA). Thus, are also investigating 6 serial cDNA samples of patients during neoadjuvant and adjuvant chemotherapy treatment. Patients are subjected to genetic testing using a 26-gene panel including the homologous recombination (HR) predisposing genes for classifying the TNBC in hereditary or sporadic. The somatic mutations identified in the tumor biopsy by using a gene panel containing frequently mutated genes in breast tumor cancer have been screened in serial plasma samples to check allele frequency of the somatic mutation in circulating DNA and to correlate to therapy response. Results: We have enrolled 32 TNBC patients of which 28 were tested by germline variants. Based on 18 samples we had 50% of pathological complete response. Pathogenic mutations were identified only in BRCA1 in 5 out of 28 (17.8%) patients. Additionally, variants of uncertain significance (VUS) were identified in 18 out of the 26 genes (64.2% - 18/28) patients, being ATM the most affected gene by VUS. In terms of somatic variants, tumor mutation burden (TMB) analysis showed that 25% has high and 75% low TMB, with no association with BRCA1 germline status. Also, we found an average three somatic variants per tumor (range 1-7) and used as tumor marks in the screening of circulating DNA in plasma

(cDNA). Somatic mutations in TP53 were identified in all tumor biopsy samples. In cDNA in plasma before treatment, confident detection of at least one tumor mutation was observed in 6 out of 8 patients (75%), including somatic mutations in TP53 and SAMD9 genes. Serial plasma cDNA samples were completely investigated for two patients until now and the results showed great association with the clinical response data suggesting that the chemotherapy-resistance mechanisms can be investigated by ctDNA in TNBC. Supported by FAPESP, CNPq and Capes.

Citation Format: Rafael R. Brianese, Giovana T. Torrezan, Marina De Brot, Maria Nirvana Formiga, Vladmir de Lima, Fabiana B. Makdissi, Dirce Maria Carraro. Investigation of treatment resistance with DNA-damage agents in patients with triple negative breast cancer by ctDNA [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2213.

Abstract P1-03-10: The implementation of a patient referral service in a Brazilian cancer center

BACKGROUND: Healthcare systems face problems of cost increases and poor delivery organization. Integrated delivery may reduce costs and improve quality and health outcomes.

OBJECTIVE: To describe how the A.C. Camargo Cancer Center, aiming at greater integration, implemented a referral service for breast cancer patients.

METHODS AND RESULTS: The process was divided in three phases: 1) AS IS ANALYSIS, 2) BENCHMARKING, 3) PILOT & IMPLEMENTATION.

1) AS IS ANALYSIS

A.C. Camargo was responsible for treating 16% of all breast cancer cases that arose from 2000 to 2012 in São Paulo State. Prior to implementation of the program, there was no special patient classification at the initial appointments.

2) BENCHMARKING

As proposed by MD Anderson Cancer Center, we used the patient's classification at the time of an appointment request (regular screenings, undiagnosed or breast cancer patient).

As proposed by Memorial Sloan Kettering Cancer Center, we used a "Physician Referral Service" staffed by "Referral Specialists" and "Trained Oncology Nurses" to collect patient information prior to the first appointment.

As suggested by Princess Margaret Cancer Center, we collected patient care data (e.g., abnormal imaging, palpable lump).

3) PILOT & IMPLEMENTATION

Phase I: Feb. 13, 2017 to Dec. 28, 2017. We reached 7% of new patients in the Breast Surgery Department (BSD): 48% were in the Cancer Group, 45% in the Abnormal Imaging Group (Undiagnosed) and 7% in the Palpable Lump Group.

New patients were classified by the Call Center. Electable cases were referred to the Nurse Navigator, who proceeded with appointments according to protocol.

Root cause analysis of non-captured patients led to the following improvements: extension of participant Call Center cells, script review, and implementation of a training program.

The Phase I results led to the following improvements: 1) reclassification of a subgroup with highly suspicious images as the "Cancer Group"; 2) Transfer of the new referral and scheduling functions to the Call Center; and 3) Implementation of new "first appointment items", personalized for each patient group. This information was displayed to the physician and operations staff in advance of the consultation.

Phase II: Dec. 29,2017 to June 28, 2018. We reached 100% of new patients in the BSD: 17% were in the Cancer Group, 23% in the Abnormal Imaging Group, 8% in the Palpable Lump Group, and 53% in the Regular Screening Group.

Phase II results led to the following improvement: 1.) Distribution of the cancer groups'first appointment items equally among surgeons.

Phase III: From June 29, 2018 to the operation. Implemented new appointment items for new clinical patients and for pre-treatment returns.

CONCLUSION: With implementation of the Referral Service, the BSD at A.C. Camargo is now able to identify the reason for each appointment before the first consultation. This practice promotes operational predictability and more effectively organizes the personalized journey of each patient, including care on the part of Nurse Navigators for the most critical cases.

REFERENCE: Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001

Citation Format: Makdissi FB, Costa Filho ER, Conti EC, Santos LC. The implementation of a patient referral service in a Brazilian cancer center [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 P1-03-10.