Clinical outcomes in estrogen receptor-positive early-stage breast cancer patients with Recurrence Score 26-30: observational real-world cohort study

Data on adjuvant chemotherapy (CT) benefit in ER + HER2‒ early-stage breast cancer (EBC) patients with Recurrence Score (RS) 26-30 are limited. This real-world study evaluated the relationships between the RS, adjuvant treatments, and outcomes in 534 RS 26-30 patients tested through Clalit Health Services (N0: n = 394, 49% CT-treated; N1mi/N1: n = 140, 62% CT-treated). The CT-treated and untreated groups were imbalanced (more high-risk clinicopathologic characteristics in CT-treated patients). With median follow-up of 8 years, Kaplan-Meier estimates for overall survival (OS), distant recurrence-free survival (DRFS), and BC-specific mortality (BCSM) were not significantly different between CT-treated and untreated N0 patients. Seven-year rates (95% CI) in CT-treated vs untreated: OS, 97.9% (94.4-99.2%) vs 97.9% (94.6-99.2%); DRFS, 91.5% (86.6-94.7%) vs 91.2% (86.0-94.6%); BCSM, 0.5% (0.1-3.7%) vs 1.6% (0.5-4.7%). For N1mi/N1 patients, OS/DRFS did not differ significantly between treatment groups; whereas BCSM did (1.3% [0.2-8.6%] vs 6.2% [2.0-17.7%] for CT-treated and untreated patients, respectively, p = 0.024).

Selective Intra-Arterial Doxorubicin Eluting Microsphere Embolization for Desmoid Fibromatosis: A Combined Prospective and Retrospective Study

Simple Summary

Desmoid fibromatoses (DFs) are locally aggressive tumors composed of monoclonal fibroblasts within an abundant extracellular matrix. Systemic treatment with doxorubicin is effective, but associated with significant toxicity. We investigated arterial doxorubicin eluting embolization (DEE), an approach that delivers high doxorubicin concentrations to the tumor with limited systemic drug exposure, in 24 patients (median age, 24 years; interquartile range, 16–34). Most patients (71%) had one or more than one prior DFs treatment (surgery, systemic therapy, or both). Patients underwent a median of two (range, 1–4) DEE treatments, with a median of 49 mg (range, 8–75) doxorubicin per treatment. Efficacy outcomes were available for 23 patients. With a median follow-up of 8 months (interquartile range, 3–13), median tumor volumes decreased by 59% (interquartile range, 40–71%). Of 23 patients, 9 (39%), 12 (52%), and 2 (9%) had a partial response, stable disease, and progressive disease, respectively. The procedure was safe and well tolerated.

Abstract

Desmoid fibromatoses (DFs) are locally aggressive tumors composed of monoclonal fibroblasts within an abundant extracellular matrix. Systemic doxorubicin treatment is effective, but toxic. We investigated arterial doxorubicin eluting embolization (DEE), an approach characterized by high drug concentrations in the tumor alongside limited systemic drug exposure. The primary and secondary endpoints were radiological response using MRI and RECIST 1.1, respectively. The study included 24 patients (median age, 24; interquartile range, 16–34 years). Data were collected prospectively for 9 patients and retrospectively for 15 patients. The most frequent tumor locations were chest/abdomen wall and neck/shoulder/axilla (29% each). Of 24 patients, 7 (24%) were treatment naïve, and 17 (71%) had received one or two prior treatments. Patients underwent a median of two treatments (range, 1–4), with a median of 49 mg (range, 8–75) doxorubicin/treatment. Efficacy outcomes were available for 23 patients. With a median follow-up of 8 months (interquartile range, 3–13), median tumor volumes decreased by 59% (interquartile range, 40–71%) and T2 signal intensity decreased by 36% (interquartile range, 19–55%). Of 23 patients, 9 (39%), 12 (52%), and 2 (9%) had a partial response, stable disease, and progressive disease, respectively. DEE was safe and well tolerated, with one reported grade 3–4 adverse event (cord injury). In conclusion, DEE was safe and achieved rapid clinical/volumetric responses in DFs.

Palbociclib in combination with sunitinib exerts a synergistic anti-cancer effect in patient-derived xenograft models of various human cancers types

The efficacy/safety of combining palbociclib (a CDK4/6 inhibitor) and sunitinib (a multi-targeted receptor tyrosine kinase inhibitor) was evaluated, using patient-derived xenograft (PDX) models. Twenty-three PDX mice models were developed from patients with various solid tumors. The mice were randomized to 4 groups (5-6 mice in each): control/palbociclib (100 mg/kg)/sunitinib (50 mg/kg)/combination. Drugs were administered orally, 5 days/week. In 17/23 PDX models (74%), the combination demonstrated a synergistic inhibitory effect vs the monotherapies ("responder" models) with no unexpected toxicities. In 13/17 responder models, where standard-of-care (SOC) was an additional comparator, the combination was more effective than SOC in 7 models, as effective in 4, and less effective in 2. The mean ± SEM experiment duration in 15/17 responder models (2/17 were excluded due to technical issues) was 86 ± 12 and 31 ± 5 days for the combination and control groups, respectively (p = 0.0002). The effect of the combination was dose-dependent. Cell-viability experiments in A549/MDA-MB-231/HT-29 cell lines and experiments using tumor-derived primary cell spheroids supported the PDX findings. In conclusion, combination of palbociclib and sunitinib exerts a synergistic anti-tumor effect without adding unexpected toxicity. A clinical trial assessing this combination is underway.

Phase 2 single arm study of nivolumab and ipilimumab (Nivo/Ipi) in previously treated classical Kaposi Sarcoma (cKS)

BACKGROUND

Classical Kaposi Sarcoma (cKS) is a rare HHV8-associated sarcoma with limited treatment options. We evaluated the efficacy and safety of nivolumab in combination with ipilimumab (Nivo/Ipi) in patients with previously treated progressive cKS.

PATIENTS AND METHODS

cKS pts with progressive disease after > 1 lines of systemic therapy and measurable disease by PET/CT and/or physical examination received nivolumab 240mg every two weeks and ipilimumab 1mg/kg every six weeks until progression or toxicity for a maximum of 24 months. The primary endpoint was overall response rate (ORR); secondary endpoints included 6-months progression free survival rate (PFS) and safety. Immune correlates were explored using IHC, DNAseq (596/648 genes) and RNAseq (exome capture transcriptome) of tumor specimens and matched blood.

RESULTS

Eighteen male patients (median age 76.5) were enrolled between April 2018 and Dec 2020. At a median follow up of 24.4 months, ORR by RECIST v1.1 was 87%. Metabolic complete response as assessed by PET CT was observed in 8 of 13 (62%) evaluable patients. 6/13 achieved pathological CR post treatment. In two patients, palliative limb amputation was prevented. Median PFS was not reached. The 6mo and 12m PFS rate was 76.5% and 58.8%, respectively. Only four patients (22%) experienced grade 3-4 adverse events. The most frequent genomic alteration was biallelic copy number loss of FOX1A gene. The majority of tumors carried a low TMB, were microsatellite stable (MSS), MMR proficient, did not express PD-L1 and displayed only low lymphocytic infiltrates, rendering them immunologically "cold".

CONCLUSIONS

This prospectively designed phase II study of nivolumab and ipilimumab demonstrates promising activity of this combination in progressive cKS representing a new treatment option in this population.

Durvalumab after concurrent chemotherapy and high-dose radiotherapy for locally advanced non-small cell lung cancer

The standard of care for stage III non-small cell lung cancer (NSCLC) is chemoradiotherapy (CRT) followed by durvalumab. Although doses higher than 66 Gy are standard in our center, they were used in only 6.9% of patients in the PACIFIC trial. We report our experience with durvalumab after high-dose radiotherapy. The database of a tertiary hospital for patients with stage III NSCLC who were treated with CRT and adjuvant durvalumab was evaluated. Progression-free survival (PFS), overall survival (OS), and local-regional failure (LRF) were measured from the administration of durvalumab. Thirty-nine patients were included. All were treated with intensity-modulated radiation (mean dose 69.9 Gy); Median follow-up time was 20.4 months (range 1–35.4). At 12 months, PFS was 49%, OS 79%, and LRF 14%. Intrathoracic failure at first progression was demonstrated in 8 (21%) patients. Adverse events requiring corticosteroids occurred in 10(25.6%) patients: pneumonitis – 6 (15.4%), hepatitis – 2 (5.1%), and arthralgia and pericarditis – 1 (2.6%). One patient (2.6%) died of pneumonitis. The occurrence of pneumonitis was significantly associated with lung V5 (55% vs. 42%, p = .04) and V20 (28% vs. 19%, p = .01) and mean lung dose (14.8 Gy vs.11.6 Gy, p = .05). The similar 12-month PFS and OS rates of our cohort and the PACIFIC trial support the use of high-dose radiotherapy in patients with stage III NSCLC. Treatment-related mortality was similar to the PACIFIC results. The intrathoracic failure rate in our cohort was lower than that reported from the PACIFIC trial, suggesting that radiation dose escalation may improve local control.

Postoperative PET-CT in patients (pts) with pathological stage III colon cancer (CC): Interim results from the first prospective validation study

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Background: A substantial number of pts with pathological stage III CC recur despite the absence of metastatic disease on pre-operative CT. In a previous large retrospective study from our institution on 348 pts, we reported that early postoperative PET-CT modified the staging and management of 13.4% of assumed stage III CC pts. The aim of the current study was to prospectively validate these results. Methods: A prospective, single-center study of pts with pathological stage III CC who underwent early postoperative PET-CT between the years 2013-2021. Results: 83 pts were accrued and 81 (48.1% males, median age 66y) were evaluable for the primary endpoint i.e. PET-CT results. Pathological stage was IIIA, IIIB and IIIC in 7 (8.6%), 56 (69.1%) and 17 (21%) of pts, respectively. Median number of lymph nodes examined and of positive nodes were 17 (range, 9-134) and 2 (range, 0-15), respectively. Post-operative PET-CT findings were significant in 7 pts (8.6%): 4 pts (4.9%) were upstaged to stage IV, 2 (2.5%) were diagnosed with a second primary malignancy, and 1 (1.2%) was both upstaged and diagnosed with another cancer. Three additional pts (3.7%) are currently undergoing evaluation for suspicious PET-CT findings. At a median follow-up of 30.6 months (range, 6.2-92), 13 of the 71 pts with true stage III CC recurred; the estimated 3y disease-free survival rate was 81%. The estimated 5y overall survival rates for the entire cohort and for true stage III pts were 82% and 90%, respectively. Of the 5 pts found to have metastatic disease based on PET-CT findings, one is scheduled to undergo potentially curative surgical removal of a solitary liver metastasis. Conclusions: Interim results from the first prospective study to evaluate the impact of early postoperative PET-CT in pts with pathological stage III CC seem to support earlier retrospective data: the use of PET-CT in this setting changed the staging and management of 8.6% of pts, including the possibility for early detection of potentially curable metastatic disease. Additional data, with more pts and longer follow-up, will be presented at the meeting.

Neutrophil-to-Lymphocyte Ratio Predicts Recurrence Pattern in Patients with Resectable Colorectal Liver Metastases

BACKGROUND

Studies have suggested that neutrophil-to-lymphocyte ratio (NLR) has value as a predictor of long-term outcomes in various cancer types. Its prognostic potential in patients with CRLM has not been thoroughly investigated. This original, retrospective study assessed the relationship between the preoperative NLR, survival outcomes, and recurrence patterns in patients after colorectal liver metastasis resection (CRLM).

METHODS

The prospectively maintained database of a tertiary medical center was queried for all patients who underwent CRLM resection between 2005 and 2017. Patients were divided into two groups: NLR <3 (normal) or >3 (high). Recurrence risk was analysed using Fine and Gray correction for competing risk method and cause specific analyses.

RESULTS

The cohort included 231 patients of whom 53 (23%) had a high neutrophil-to-lymphocyte ratio. At presentation, 35% had synchronous disease and 48% had a solitary metastasis; median tumor size was 2 cm. Patients with a high NLR had a significantly higher rate of simultaneous colorectal resection (P = 0.01). A high NLR was independently associated with worse OS (P = 0.02), worse DFS (P = 0.03), and higher risk of recurrence (P = 0.048), specifically recurrence with an extrahepatic pattern (P = 0.03).

CONCLUSIONS

A high preoperative NLR was independently associated with poorer survival outcomes and extrahepatic recurrence pattern. The NLR appears to have prognostic importance in CRLM and may serve as a surrogate marker of aggressive systemic disease after resection. These findings warrant external validation, preferably in a prospective design.

BIOM-01. TYROSINE KINASE INHIBITORS AS A TREATMENT OF SYMPTOMATIC CNS METASTASES IN ONCOGENE-DRIVEN NSCLC

BACKGROUND

Central nervous system (CNS) metastases occur frequently in oncogene-driven non-small cell lung cancer (NSCLC). Standard treatment (i.e surgery, whole brain radiation therapy or stereotactic radiosurgery) approaches can potentially delay systemic treatment and/or result in neurocognitive impairment. Recently, next generation tyrosine kinase inhibitors (TKIs) have demonstrated a remarkable intracranial activity. However, most clinical trials did not enroll patients with neurological symptoms. Our study aims to assess the CNS activity of targeted therapy in this patient population.

METHOD

We present a case series of nine NSCLC patients with either EGFR mutation of ALK rearrangement and symptomatic CNS metastases that were treated with TKIs, without radiation therapy or surgery. Clinicopathological characteristics, treatment and outcome were analyzed.

RESULTS

Most patients presented with symptomatic CNS metastases at time of metastatic disease presentation (6/9 patients). Additionally, the majority of patients had leptomingeal disease (6/9 patients) and multiple parenchymal metastases. Patients presented with a variety of CNS symptoms with the most common being nausea, vomiting, headache and confusion. Five patients were treated with Osimertinib. One patient with ALK rearrangement was treated with Lorlatinib. The remaining 3 patients received either Gefitinib or Afatinib. Most patients (6/9 patients) responded rapidly both clinically and radiographically to the targeted treatment, with a marked correlation between systemic and intracranial radiographic response.

CONCLUSION

Upfront use of next generation TKIs in patients with oncogene-driver NSCLC with symptomatic CNS metastases is associated with reasonable intracranial activity and represents a valuable treatment option.

Tyrosine Kinase Inhibitors as a Treatment of Symptomatic CNS Metastases in Oncogene-Driven NSCLC

Central nervous system (CNS) metastases occur frequently in oncogene-driven non-small cell lung cancer (NSCLC). Standard treatment approaches can potentially delay systemic treatment (surgical intervention) or result in neurocognitive impairment (radiotherapy). Recently, next-generation tyrosine kinase inhibitors (TKIs) have demonstrated remarkable intracranial activity. However, most clinical trials did not enroll patients suffering neurological symptoms. Our study aimed to assess the CNS activity of targeted therapies in this patient population. We present a case series of nine NSCLC patients with either EGFR mutation or ALK rearrangement and symptomatic CNS metastases that were treated with TKIs. Clinicopathological characteristics, treatment, and outcomes were analyzed. Most patients presented with symptomatic CNS metastases at time of metastatic disease presentation (6/9). Additionally, the majority of patients had leptomeningeal disease (6/9) and multiple parenchymal metastases. Patients presented with a variety of CNS symptoms with the most common being nausea, vomiting, headache, and confusion. Most patients (6/9) responded rapidly both clinically and radiographically to the targeted treatment, with a marked correlation between systemic and intracranial radiographic response. In conclusion, upfront use of next-generation TKIs in patients with oncogene-driven NSCLC with symptomatic CNS metastases is associated with reasonable intracranial activity and represents a valuable treatment option.

Abstract 5054: Synergistic anti-cancer activity of palbociclib in combination with sunitinib in patient-derived xenograft (PDX) models of various human cancers types

Introduction: Treatment for cancer, particularly in later lines, is often inadequate. Combinational therapies targeting several signaling pathways simultaneously are considered a promising approach, with limited clinical evidence. Effectiveness of such combinations can be explored in patient-derived xenograft (PDX) tumor models, which more accurately represent human tumor biology, drug responsiveness, and treatment-related toxicity than standard xenograft models derived from established human cancer cell lines.

Objectives: To evaluate, in PDX models, the anti-tumor effect and safety of combinational therapy including a CDK4/6 inhibitor (palbociclib) plus a multi-targeted receptor tyrosine kinase inhibitor (mtRTKI; sunitinib).

Methods: Overall, 20 PDX models were developed from patients with various solid tumors. For each, tumor was implanted subcutaneously in immune-deficient mice (NRG or NSG). The mice were randomized to 4 treatment groups: vehicle as control, palbociclib (100 mg/kg), sunitinib (50 mg/kg), or combination thereof. Each treatment group included 5-6 mice (18/20 models). Drugs were administered orally, 5 days per week. Tumor volume was monitored twice a week with digital caliper. Mice body weight and clinical signs were examined twice a week to evaluate toxicity.

Results: The mean experiment time (all experiments) was 66 days (SEM, 10 days; range, 15-170 days). In 14 of the 20 evaluated models (70%), including those for cholangiocarcinoma, breast, lung, pancreas, colon, stomach, and ovarian cancer, combinational therapy with palbociclib and sunitinib had significantly superior anti-cancer activity compared to either drug alone, without any unexpected toxicity. Mean duration of response in these 14 models was 72 days (SEM, 12 days). The combination of palbociclib and sunitinib prevented tumor growth, and in 3 models reduced tumor size. In the 2 PDX models developed from patients with palbociclib-resistant disease, the combination overcame tumor resistance to palbociclib. In 5 of the models which demonstrated synergy between palbociclib and sunitinib, the effect of administrating 2-fold lower doses of both drugs was evaluated. The lower doses were shown to suppress tumor growth in a dose-response manner.

Conclusions: These PDX results suggest that the combination of palbociclib and sunitinib exert a synergistic anti-tumor effect on multiple tumor types without adding unexpected toxicity.

Citation Format: Neta Moskovits, Idit Peretz, Eva Chausky, Raisa Meerson, Ella Itzhaki, Noga Marsiano, Nofar Shmuel, Ranny Yaffe, Natalia Edison, Tal Goldman, Salomon Stemmer. Synergistic anti-cancer activity of palbociclib in combination with sunitinib in patient-derived xenograft (PDX) models of various human cancers types [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5054.

A phase II single-arm study of nivolumab and ipilimumab (Nivo/Ipi) in previously treated classical Kaposi sarcoma (CKS)

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Background: CKS is a mesenchymal neoplasm associated with HHV8 infection. Though recombinant INFa is approved for treatment of AIDS-related KS, data is limited regarding the role of immune modulation in CKS therapy. Based on favorable responses in viral-induced cancers, we hypothesized that CTLA-4 and PD-1 blockade can induce tumor regression in CKS. We present pre-planned interim analysis of a phase II study of Nivo/Ipi in previously treated progressive CKS. Methods: CKS pts with progressive disease after > 1 line of systemic therapy and measurable disease received nivolumab 240mg d1,15,28 and ipilimumab 1mg/kg d1 q42 days until progression or toxicity. The primary endpoint was overall response rate (ORR) evaluated clinically, radiologically (RECIST) and metabolically (FDG-PET). Secondary endpoints include 6-months progression free survival rate (PFS) and safety. Exploratory endpoints included PD-L1/MMR by IHC, DNAseq (596 genes)/RNAseq (whole transcriptome) of tumor and matched blood specimens to explore CKS genomic traits and IO correlates: TMB and MSI status, MMR and PD-L1 protein expression, and immune gene transcript expression (PD-1, PD-L1, CTLA-4, and others) (Tempus Labs, Chicago, IL, USA). Results: Fifteen patients were enrolled and evaluable (Apr18-Jan20). Median age 72.5 (61-81), all male. At a median FU of 15.7 mo ORR as per RECIST was 66% (9 pts PR, 1 pt CR, 2 pts SD, 3 pts NE). Clinical ORR was 87% and metabolic ORR was 60%. Median PFS was not reached, 6mo PFS rate was 85% and 1y PFS rate was 75%. The safety profile was as expected with all pts experiencing G1 toxicity, 3 pts with G2 toxicity (1 hepatic, 2 asymptomatic lipase increase) and 2 pts with G3 toxicity (1 colitis, 1 asymptomatic lipase increase). One SAE was reported (TIA considered not related to therapy) and treatment was discontinued in 3 pts. Correlative results are available for 8 pts showing a trend for copy number loss in genes with tumor-suppressive activity (FOXA1, ELF3), no PDL1 expression, low TMB, microsatellite stability, but marked overexpression of CTLA-4, PD-1, PDL-1, CD40, OX40 and LAG3 RNA immune transcripts. Conclusions: The interim analysis of this prospective phase II study of nivolumab and low-dose ipilimumab demonstrates promising activity in progressive CKS, with 66% ORR and a 6mo PFS rate of 85%. Toxicity profile is as expected in this class of drugs. Correlative studies are preliminary, but warrant further investigation into genomic traits and immune gene expression profiles. Clinical trial information: NCT03219671. Clinical trial information: NCT03219671 .

Safety and efficacy of VB-111, an anticancer gene therapy, in patients with recurrent glioblastoma: results of a phase I/II study

BACKGROUND

VB-111 is a non-replicating adenovirus carrying a Fas-chimera transgene, leading to targeted apoptosis of tumor vascular endothelium and induction of a tumor-specific immune response. This phase I/II study evaluated the safety, tolerability, and efficacy of VB-111 with and without bevacizumab in recurrent glioblastoma (rGBM).

METHODS

Patients with rGBM (n = 72) received VB-111 in 4 treatment groups: subtherapeutic (VB-111 dose escalation), limited exposure (LE; VB-111 monotherapy until progression), primed combination (VB-111 monotherapy continued upon progression with combination of bevacizumab), and unprimed combination (upfront combination of VB-111 and bevacizumab). The primary endpoint was median overall survival (OS). Secondary endpoints were safety, overall response rate, and progression-free survival (PFS).

RESULTS

VB-111 was well tolerated. The most common adverse event was transient mild-moderate fever. Median OS time was significantly longer in the primed combination group compared with both LE (414 vs 223 days; hazard ratio [HR], 0.48; P = 0.043) and unprimed combination (414 vs 141.5 days; HR, 0.24; P = 0.0056). Patients in the combination phase of the primed combination group had a median PFS time of 90 days compared with 60 in the LE group (HR, 0.36; P = 0.032), and 63 in the unprimed combination group (P = 0.72). Radiographic responders to VB-111 exhibited characteristic, expansive areas of necrosis in the areas of initial enhancing disease.

CONCLUSIONS

Patients with rGBM who were primed with VB-111 monotherapy that continued after progression with the addition of bevacizumab showed significant survival and PFS advantage, as well as specific imaging characteristics related to VB-111 mechanism of action. These results warrant further assessment in a randomized controlled study.

Investigating the utility of breast cancer (BC) molecular signatures and immune signature profiling (ISP) as predictors of pathological complete response (pCR) to neoadjuvant chemotherapy + trastuzumab (NAC+T) in HER2+ BC

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Background: Trastuzumab targets HER2 directly as well as contributes to activation of the immune system against the tumor. We investigated the utility of BC molecular signatures and ISP as predictors of pCR to NAC+T in HER2+ BC pts. Methods: The analysis included 73 consecutive HER2+ BC pts with pathological samples at diagnosis, who received NAC+T. RNA was extracted from 73/22 biopsy/surgical specimens (FFPE). RNA was analyzed using NanoString PanCancer Immunoncology 360 (IO360) panel with PAM50 spike-in. Raw gene counts were log2-transformed and normalized (using housekeeping genes). The analysis assessed 47 gene signatures including immune related and PAM50 signatures. Signatures were computed after removing samples with low expression of the housekeeping genes and normalization. Signature scores range from ~0 to 10 and have an average value of 5 in tumor samples from The Cancer Genome Atlas. Results: Overall, 46% of the pts achieved pCR; of 13 pts who were IHC 2+ and FISH positive, one achieved pCR. Significant associations were found between response to NAC+T (pCR, no response) and molecular signatures/ISP from the initial biopsy (Table). For pts who did not experience pCR and who underwent surgery, paired sample analysis was performed assessing molecular signatures/ISP in the initial biopsy sample vs the surgical sample. This analysis demonstrated a significant increase post-treatment (compared to the initial biopsy sample) in Risk of Recurrence (ROR) score (p=.036), interferon (IFN) downstream signature (p=.038), and antigen‐processing machinery (APM) loss (p=.002). Conclusions: Combining molecular BC signatures and ISP on biopsy samples may have a predictive value in HER2+BC pts for whom NAC+T is considered. Luminal A pts and IHC 2+ (FISH positive) are unlikely to achieve pCR with NAC+T. [Table: see text]

Musical and vocal emotion perception for cochlear implants users

Cochlear implants can successfully restore hearing in profoundly deaf individuals and enable speech comprehension. However, the acoustic signal provided is severely degraded and, as a result, many important acoustic cues for perceiving emotion in voices and music are unavailable. The deficit of cochlear implant users in auditory emotion processing has been clearly established. Yet, the extent to which this deficit and the specific cues that remain available to cochlear implant users are unknown due to several confounding factors. Here we assessed the recognition of the most basic forms of auditory emotion and aimed to identify which acoustic cues are most relevant to recognize emotions through cochlear implants. To do so, we used stimuli that allowed vocal and musical auditory emotions to be comparatively assessed while controlling for confounding factors. These stimuli were used to evaluate emotion perception in cochlear implant users (Experiment 1) and to investigate emotion perception in natural versus cochlear implant hearing in the same participants with a validated cochlear implant simulation approach (Experiment 2). Our results showed that vocal and musical fear was not accurately recognized by cochlear implant users. Interestingly, both experiments found that timbral acoustic cues (energy and roughness) correlate with participant ratings for both vocal and musical emotion bursts in the cochlear implant simulation condition. This suggests that specific attention should be given to these cues in the design of cochlear implant processors and rehabilitation protocols (especially energy, and roughness). For instance, music-based interventions focused on timbre could improve emotion perception and regulation, and thus improve social functioning, in children with cochlear implants during development.

The role of high-dose chemotherapy (CT) and stem-cell support in high-risk stage II, locally advanced, and responding stage IV breast cancer (BC): The Israeli experience with 20 years median follow-up

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Background: Lately, updated data led the medical community to reconsider the use of intensive CT with stem-cell support for selected groups of BC patients (pts). Herein, we provide an update on a study investigating the efficacy, feasibility, and toxicity of high-dose CT with stem-cell support in pts with high-risk stage II, chemosensitive stage III and IV BC. Methods: The protocol offered adjuvant/neoadjuvant/induction doxorubicin-based CT, 75-90 mg/m2 X 4 courses followed by high-dose CT (cyclophosphamide 6000 mg/m2, carboplatin 800 mg/m2, and thiotepa 500 mg/m2) and autologous stem cell support with growth factors. Post-transplant local radiotherapy was delivered. Pts who were hormone receptor (HR) positive received Tamoxifen. Results: From 2/1994 to 11/1998, 292 BC pts were referred to the study from all Israeli oncology centers. Median follow-up from transplant was 20 (range, 18-22) years; 119 had stage 2 disease (42 with 4-9 positive nodes, 77 with ≥10 positive nodes); 87 had stage 3 disease, of whom 50 had locally advanced/inflammatory BC treated with neoadjuvant CT; and 86 had chemosensitive stage IV BC. Two acute transplant-related deaths and one death due to late transplant-related toxicity were reported. Median age at transplant was 45 (range, 24-63) years. Overall survival (OS) by HR status is presented in the table. In total, 167 of the 292 pts died (based on death status data retrieved from the Registry of the Ministry of the Interior), representing OS of 42%. The OS rates for stage II, III, and IV were 55%, 45%, and 23%, respectively. Conclusions: Long-term accurate follow-up of pts receiving well-defined treatments remains an important tool in cancer research. High-dose CT with stem-cell support could represent a therapeutic/curative option in select BC patients in all disease stages. Reintroduction of this approach should be re-examined. [Table: see text]

Singing in the Brain: Independence of Lyrics and Tunes

Why is vocal music the oldest and still the most popular form of music? Very possibly because vocal music involves an intimate combination of speech and music, two of the most specific, high-level skills of human beings. The issue we address is whether people listening to a song treat the linguistic and musical components separately or integrate them within a single percept. Event-related potentials were recorded while musicians listened to excerpts from operas sung a capella. Excerpts were ended by semantically congruous or incongruous words sung either in or out of key. Results clearly demonstrated the independence of lyrics and tunes, so that an additive model of semantic- and harmonic-violations processing predicted the data extremely well. These results are consistent with a modular organization of the human cognitive system and open new perspectives in the search for the similarities and differences between language and music processing.

Can we lose memory for music? A case of music agnosia in a nonmusician

Abstract A follow-up study of a patient, C.N., with a severe auditory agnosia limited to music is reported. After bilateral temporal lobe damage, C.N., whose cognitive and speech functions are otherwise normal, is totally unable to identify or to experience a sense of familiarity with musical excerpts that were once highly familiar to her. However, she can recognize the lyrics that usually accompany the songs. She can also identify familiar sounds, such as animal cries. Thus, her agnosia appears highly specific to music. The functional nature of her deficit has been investigated through various perceptual tasks. She was initially severely impaired in processing pitch sequential structure but has always enjoyed normal processing of temporal structure. This selective disturbance for sequential pitch information can hardly account for her tune agnosia since processing of pitch variations has dramatically improved over the years. This recovery was not accompanied by any signs of improvement in music recognition, which remains extremely poor. Moreover, the fact that she has never been able to hum tunes from memory argues for a basic memory disturbance. Thus, she was tested here with a series of tests aiming at assessing her memory for familiar and unfamiliar music. The results show that C.N. has now recovered most perceptual skills and that despite a transient ability to exhibit knowledge of familiar music under restricted circumstances, she is markedly impaired at naming a tune and at judging its familiarity, as well as at memorizing familiar as well as novel music. This deficit was found to be not only modality-specific but music-specific as well. The findings suggest the existence of a perceptual memory that is specialized for music and that can be selectively damaged so as to prevent most forms of recognition ability.

Introduction to The neurosciences and music IV: learning and memory

The conference entitled "The Neurosciences and Music-IV: Learning and Memory'' was held at the University of Edinburgh from June 9-12, 2011, jointly hosted by the Mariani Foundation and the Institute for Music in Human and Social Development, and involving nearly 500 international delegates. Two opening workshops, three large and vibrant poster sessions, and nine invited symposia introduced a diverse range of recent research findings and discussed current research directions. Here, the proceedings are introduced by the workshop and symposia leaders on topics including working with children, rhythm perception, language processing, cultural learning, memory, musical imagery, neural plasticity, stroke rehabilitation, autism, and amusia. The rich diversity of the interdisciplinary research presented suggests that the future of music neuroscience looks both exciting and promising, and that important implications for music rehabilitation and therapy are being discovered.

Mécanismes cérébraux impliqués dans l’interaction entre la douleur et les émotions

INTRODUCTION

Pain is an unpleasant and intrusive sensation, warning of actual or potential tissue damage. Over the last fifteen years, functional cerebral imaging research has demonstrated the involvement of many cerebral structures in the experience of pain.

BACKGROUND

Intimately linked to the notion of suffering, the affective dimension of pain relies on neurophysiological systems partly distinct anatomically from those involved more specifically in its sensory dimension. Some pathways convey nociceptive information to the somatosensory cortex and the insula, contributing to the sensory aspects of pain (e.g.: sensory intensity), and secondarily, to its affective dimension. Other pathways project directly to the anterior cingulate cortex, the insula, the amygdala and to the prefrontal cortices, which are structures involved in the affective dimension of pain (unpleasantness of pain and regulation of autonomic and behavioral responses). Interestingly, these latter regions are an integral part of the cerebral emotional networks.

PERSPECTIVES AND CONCLUSION

This close anatomical relationship between pain and emotions circuits could explain the powerful emotional impact of pain as well as the reciprocal modulatory effect of emotions on pain observed in clinical and experimental studies. More specifically, this modulatory effect might reflect interactions between emotional and nociceptive systems in the prefrontal and cingulate cortices, ventral striatum, amygdala and hippocampal regions. Taken together, these observations further attest to the emotional nature of pain experience.

Education, age, and the Brown-Peterson technique

In this article, we discuss the effects of education level and age on short-term memory. The performance of young and elderly persons was compared on an adapted version of the Brown-Peterson procedure. Participants were asked to report consonant trigrams, after variable time periods, during which they performed a mental addition task or an articulation task. A control condition consisted of a no-interference task. Both age groups were divided according to individual educational level (greater or less than the median number of school years in each age group). The results revealed a significant effect of education. Moreover, the education effect interacted with the task: participants with less education were more impaired in mental addition than in articulation. However, neither the age effect nor the interactions involving age reached significance. These results indicate that education, to a greater extent than age, should be considered a determining factor of performance when interpolated tasks of high demand are used with the Brown-Peterson procedure.

Divided attention between lyrics and tunes of operatic songs: evidence for independent processing

Excerpts from French operatic songs were used to evaluate the extent to which language and music compete for processing resources. Do these two dimensions conflict? Are they integrated into a single percept? Or are they independent? The final word of each excerpt was either semantically congruous or incongruous relative to the prior linguistic context and was sung either in or out of key. Participants were asked to detect either the semantic or the melodic incongruity (single task) or both (dual task). We predicted a dual-task deficit if these tasks conflicted and no deficit if they were either independent or integrated. In order to distinguish between these last two outcomes, trial-by-trial contingency analyses were also computed, predicting no correlation if the tasks were conflicting or independent, a positive correlation under the assumption of integration and a negative correlation if dividing attention is impossible. Our results show similar levels of performance in single and dual tasks and no correlation between dual-task judgments, thus suggesting that semantic and melodic aspects of language are processed by independent systems. In addition, a comparison between musicians and nonmusicians shows that these conclusions are independent of musical expertise.

A developmental study of the affective value of tempo and mode in music

Do children use the same properties as adults in determining whether music sounds happy or sad? We addressed this question with a set of 32 excerpts (16 happy and 16 sad) taken from pre-existing music. The tempo (i.e. the number of beats per minute) and the mode (i.e. the specific subset of pitches used to write a given musical excerpt) of these excerpts were modified independently and jointly in order to measure their effects on happy-sad judgments. Adults and children from 3 to 8 years old were required to judge whether the excerpts were happy or sad. The results show that as adults, 6--8-year-old children are affected by mode and tempo manipulations. In contrast, 5-year-olds' responses are only affected by a change of tempo. The youngest children (3--4-year-olds) failed to distinguish the happy from the sad tone of the music above chance. The results indicate that tempo is mastered earlier than mode to infer the emotional tone conveyed by music.

Are text and tune of familiar songs separable by brain damage?

The recognition of text and tune in songs was examined in a music-agnosic patient and five matched controls. Listeners had to focus on one component of the song at a time (text or music) and had to decide whether the component was familiar or unfamiliar. Songs were either matched (i.e., an original familiar or an original unfamiliar song) or mismatched (a combination of a familiar component with an unfamiliar one). Normal listeners displayed response patterns that are congruent with those obtained previously in different experimental settings and which showed that text and tune are difficult to separate. Data collected in the patient, however, suggest some independence between text and music in songs. Moreover, the usual asymmetry in favor of text was much reduced when later verses were used. Overall, the results are interpreted as revealing strong association, not integration, between the musical and the verbal component of familiar songs.

Brain specialization for music. New evidence from congenital amusia

Brain specialization for music refers to the possibility that the human brain is equipped with neural networks that are dedicated to the processing of music. Finding support for the existence of such music-specific networks suggests that music may have biological roots. Conversely, the discovery that music may have systematic associations with other cognitive domains or variable brain organization across individuals supports the view that music is a cultural artifact. Currently, the evidence favors the biological perspective. There are numerous behavioral indications that music-specific networks are isolable in the brain. These neuropsychological observations are briefly reviewed here with special emphasis on a new condition, that of congenital amusia (also commonly referred to as tone deafness).

Cortical deafness to dissonance

Ordinary listeners, including infants, easily distinguish consonant from dissonant pitch combinations and consider the former more pleasant than the latter. The preference for consonance over dissonance was tested in a patient, I.R., who suffers from music perception and memory disorders as a result of bilateral lesions to the auditory cortex. In Experiment 1, I.R. was found to be unable to distinguish consonant from dissonant versions of musical excerpts taken from the classical repertoire by rating their pleasantness. I.R.'s indifference to dissonance was not due to a loss of all affective responses to music, however, since she rated the same excerpts as happy or sad, as normal controls do. In Experiment 2, I.R.'s lack of responsiveness to varying degrees of dissonance was replicated with chord sequences which had been used in a previous study using PET, in examining emotional responses to dissonance. A CT scan of I.R.'s brain was co-registered with the PET activation data from normal volunteers. Comparison of I.R.'s scan with the PET data revealed that the damaged areas overlapped with the regions identified to be involved in the perceptual analysis of the musical input, but not with the paralimbic regions involved in affective responses. Taken together, the findings suggest that dissonance may be computed bilaterally in the superior temporal gyri by specialized mechanisms prior to its emotional interpretation.

Patterns of music agnosia associated with middle cerebral artery infarcts

The objective of the study is to evaluate if the rupture of an aneurysm located on the middle cerebral artery (MCA) results in disorders of music recognition. To this aim, 20 patients having undergone brain surgery for the clipping of a unilateral left (LBS), right (RBS) or bilateral (BBS) aneurysm(s) of the MCA and 20 neurologically intact control subjects (NC) were evaluated with a series of tests assessing most of the abilities involved in music recognition. In general, the study shows that a ruptured aneurysm on the MCA that is repaired by brain surgery is very likely to produce deficits in the auditory processing of music. The incidence of such a deficit was not only very high but also selective. The results show that the LBS group was more impaired than the NC group in all three tasks involving musical long-term memory. The study also uncovered two new cases of apperceptive agnosia for music. These two patients (N.R. and R.C.) were diagnosed as such because both exhibit a clear deficit in each of the three music memory tasks and both are impaired in all discrimination tests involving musical perception. Interestingly, the lesions overlap in the right superior temporal lobe and in the right insula, making the two new cases very similar to an earlier case report. Altogether, the results are also consistent with the view that apperceptive agnosia results from damage to right hemispheric structures while associative agnosia results from damage to the left hemisphere.

Laterality effects in processing tonal and atonal melodies with affective and nonaffective task instructions

Right-handed university subjects were presented with monaural melodies that either conformed to the rules of the Western tonal system (tonal melodies) or that systematically deviated from it (atonal melodies) while containing similar contours and pitch skips. Subjects were tested under two different task instructions. One group was requested to judge whether each melody sounded correct or not (the nonaffective task); the other group had to judge whether each melody sounded pleasant or not (the affective task). The nonaffective task was found to elicit essentially no ear difference. In contrast, the affective instruction induced opposite and reliable laterality effects, depending on the valence of the response. The pleasant responses were indicative of a left hemisphere predominance and the unpleasant responses of a right hemisphere predominance. The results are consistent with the claim that the left hemisphere is biased toward positive emotions and the right to negative emotions. Moreover, the results suggest that affective appreciation of melodies is dissociable from their nonaffective judgment.

Frontal processing and auditory perception

Disordered processing of the pattern in sound over time has been observed in a number of clinical disorders, including developmental dyslexia. This study addresses the brain mechanisms required for the perception of such a pattern. We report the systematic evaluation of temporal perception in a patient with a single intact right auditory cortex and a large right frontal lobe lesion. A striking dissociated deficit was demonstrated in the perception of temporal pattern at the level of tens or hundreds of milliseconds. This proves that, contrary to common belief, mechanisms in the pathway up to and including the primary auditory cortex are not sufficient for the normal perception of temporal pattern. This work suggests a need for frontal processing for the normal perception of auditory pattern.

Contribution of different cortical areas in the temporal lobes to music processing

Music processing ability was studied in 65 right-handed patients who had undergone unilateral temporal cortectomy for the relief of intractable epilepsy, and 24 matched normal controls. The ability to recognize changes in note intervals and to distinguish between different rhythms and metres was tested by presentation of sequences of simple musical phrases with variations in either pitch or temporal dimensions. The responses (right or wrong) enabled us to determine in which component of the music processing mechanism the patients had deficits and hence, knowing the positions of the surgical lesions, to identify their separate cerebral locations. The results showed that a right temporal cortectomy impaired the use of both contour and interval information in the discrimination of melodies and a left temporal cortectomy impaired only the use of interval information. Moreover, they underlined the importance of the superior temporal gyrus in melody processing. The excision of a part of the auditory areas (posterior part of the superior temporal gyrus) was found to be most detrimental for pitch and temporal variation processing. In the temporal dimension, we observed a dissociation between metre and rhythm and the critical involvement of the anterior part of the superior temporal gyrus in metric processing. This study highlights the relevance of dissociating musical abilities into their most significant cognitive components in order to identify their separate cerebral locations.

Exposure effects on music preference and recognition

In three experiments, the effects of exposure to melodies on their subsequent liking and recognition were explored. In each experiment, the subjects first listened to a set of familiar and unfamiliar melodies in a study phase. In the subsequent test phase, the melodies were repeated, along with a set of distractors matched in familiarity. Half the subjects were required to rate their liking of each melody, and half had to identify the melodies they had heard earlier in the study phase. Repetition of the studied melodies was found to increase liking of the unfamiliar melodies in the affect task and to be best for detection of familiar melodies in the recognition task (Experiments 1, 2, and 3). These memory effects were found to fade at different time delays between study and test in the affect and recognition tasks, with the latter leading to the most persistent effects (Experiment 2). Both study-to-test changes in melody timbre and manipulation of study tasks had a marked impact on recognition and little influence on liking judgments (Experiment 3). Thus, all manipulated variables were found to dissociate the memory effects in the two tasks. The results are consistent with the view that memory effects in the affect and recognition tasks pertain to the implicit and explicit forms of memory, respectively. Part of the results are, however, at variance with the literature on implicit and explicit memory in the auditory domain. Attribution of these differences to the use of musical material is discussed.

Music and emotion: perceptual determinants, immediacy, and isolation after brain damage

This study grew out of the observation of a remarkable sparing of emotional responses to music in the context of severe deficits in music processing after brain damage in a non-musician. Six experiments were designed to explore the perceptual basis of emotional judgments in music. In each experiment, the same set of 32 excerpts taken from the classical repertoire and intended to convey a happy or sad tone were presented under various transformations and with different task demands. In Expts. 1 to 3, subjects were required to judge on a 10-point scale whether the excerpts were happy or sad. Altogether the results show that emotional judgments are (a) highly consistent across subjects and resistant to brain damage; (b) determined by musical structure (mode and tempo); and (c) immediate. Experiments 4 to 6 were designed to asses whether emotional and non-emotional judgments reflect the operations of a single perceptual analysis system. To this aim, we searched for evidence of dissociation in our brain-damaged patient, I.R., by using tasks that do not require emotional interpretation. These non-emotional tasks were a 'same-different' classification task (Expt. 4), error detection tasks (Expt. 5A,B) and a change monitoring task (Expt. 6). I.R. was impaired in these non-emotional tasks except when the change affected the mode and the tempo of the excerpt, in which case I.R. performed close to normal. The results are discussed in relation to the possibility that emotional and non-emotional judgments are the products of distinct pathways.

Processing prosodic and musical patterns: a neuropsychological investigation

To explore the relationship between the processing of melodic and rhythmic patterns in speech and music, we tested the prosodic and musical discrimination abilities of two "amusic" subjects who suffered from music perception deficits secondary to bilateral brain damage. Prosodic discrimination was assessed with sentence pairs where members of a pair differed by intonation or rhythm, and musical discrimination was tested using musical-phrase pairs derived from the prosody of the sentence pairs. This novel technique was chosen to make task demands as comparable as possible across domains. One amusic subject showed good performance on both linguistic and musical discrimination tasks, while the other had difficulty with both tasks. In both subjects, level of performance was statistically similar across domains, suggesting shared neural resource for prosody and music. Further tests suggested that prosody and music may overlap in the processes used to maintain auditory patterns in working memory.

[Dissociations between music and language functions after cerebral resection: A new case of amusia without aphasia]

We present the neuropsychological study of a patient, I.R., who sustained bilateral damage to the temporal lobes and to the right frontal lobe as a result of successive brain surgeries that occurred ten years earlier. The patient is 40 years old and right-handed; she had no special training in music or in language, representing, therefore, the large majority of listeners. Her performance is compared to that of four neurologically intact subjects who are closely matched in terms of education, sex and age. In the present study, we report I.R.'s performance on various tests aiming at assessing her general cognitive functioning with a particular focus on auditory aspects. The results show that, despite extensive damage to her auditory cortex, I.R.'s speech abilities are essentially intact (see Tables 1 and 2). The only impairments that are detected in the language domain are related to a short-term memory deficit, to some abnormal sensitivity to retroactive interference in long-term memory (see Table 3) and to articulation. These difficulties do not, however, affect linguistic communication, which is obviously undisturbed I.R. is not aphasic). Similarly, I.R. does not experience any difficulty in the recognition and memorization of familiar sounds such as animal cries, traffic noises and the like (see Tables 5 and 7). In contrast, I.R. is severely impaired in most musical abilities: She can no longer discriminate nor identify melodies that were once highly familiar to her; she can no longer discriminate nor memorize novel melodies (see Table 4). Her pattern of musical losses is compatible with a basic and severe perceptual deficit that compromises access to and registration in memory systems. The observation that the auditory impairment affects music and spares language and environmental sounds refers to a neuropsychological condition that is known as music agnosia. I.R. represents, to our knowledge, the fourth case of music agnosia available in the literature (Peretz et al., 1994; Griffiths et al., 1997). The existence of such cases suggests that music processing is not mediated by a general-purpose auditory architecture but by specialized cortical subsystems. Not only does I.R. suffer from music agnosia, but she is also impaired in the discrimination and recognition of musical instruments and of human voices (see Table 5). These latter two deficits probably do not result from the music agnosic condition. Rather, they seem to reflect damage to adjacent brain areas that are specialized in timbre processing (see Peretz. et al., 1994, for the relevant discussion). It is also worth mentioning that I.R. appears to be impaired in musical expressive abilities as well: I.R. can no longer sing a single note. Thus, her losses are rather general in the musical domain, hence justifying the classification of her case as amusia. Cases of amusia without aphasia are relatively frequent in the neuropsychological literature. However, all of these reported cases are anecdotal. Thus, in the present study, special focus is given to the measurement and direct comparison of performance in the language and music domain; in both domains, task characteristics and materials were as similar as possible. To this aim, the lyrics and the tune of the same popular song excerpts were used. The musical and the spoken parts were presented separately in a primed familiarity decision task and in a memory recognition task. In both situations, I.R. performs at or close to chance when she has to deal with music, whereas she recognizes easily and performs normally on the spoken material (see Tables 6 and 7). These results clearly argue for the autonomy of music and language in the processing of auditory information.

Role of familiarity in auditory discrimination of musical instrument: a laterality study

Normal subjects were presented with dichotic pairs of sounds differing in pitch-timbre combination. Their task was to detect a fixed target sound that occurred randomly but equally often in the right and the left ear in two-thirds of the trials. Half the subjects performed this task with sounds produced by familiar natural instruments (violin, flute, guitar and drum), and the other subjects performed the same task but with the sounds played backwards, hence being less recognizable. Subjects were quicker and more accurate in discriminating forwards than backwards played sounds, hence exhibiting sensitivity to familiarity with musical instrument sounds. Recourse to this knowledge was, however, not associated to a shift in laterality. For both familiar and unfamiliar sounds, a robust left-ear advantage (LEA) was observed.