Vanishing bile duct syndrome as a presentation of Hodgkin's lymphoma

Vanishing bile duct syndrome is an uncommon condition characterised by the progressive loss and disappearance of bile ducts. It is an acquired form of cholestatic liver disease presenting with hepatic ductopenia (loss of >50% bile ducts in the portal areas). We present a case of vanishing bile duct syndrome as a presentation of Hodgkin's lymphoma who was treated with standard-of-care chemotherapy-doxorubicin, bleomycin, vinblastine and dacarbazine (along with brief administration of rituximab), which led to complete response and normalisation of liver function.

Quality-of-life outcomes and risk prediction for patients randomized to nivolumab plus ipilimumab vs nivolumab on LungMAP-S1400I

BACKGROUND

An important issue for patients with cancer treated with novel therapeutics is how they weigh the effects of treatment on survival and quality of life (QOL). We compared QOL in patients enrolled to SWOG S1400I, a substudy of the LungMAP biomarker-driven master protocol.

METHODS

SWOG S1400I was a randomized phase III trial comparing nivolumab plus ipilimumab vs nivolumab for treatment of immunotherapy-naïve disease in advanced squamous cell lung cancer. The primary endpoint was the MD Anderson Symptom Inventory-Lung Cancer severity score at week 7 and week 13 with a target difference of 1.0 points, assessed using multivariable linear regression. A composite risk model for progression-free and overall survival was derived using best-subset selection.

RESULTS

Among 158 evaluable patients, median age was 67.6 years and most were male (66.5%). The adjusted MD Anderson Symptom Inventory-Lung Cancer severity score was 0.04 points (95% confidence interval [CI] = -0.44 to 0.51 points; P = .89) at week 7 and 0.12 points (95% CI = -0.41 to 0.65; P = .66) at week 13. A composite risk model showed that patients with high levels of appetite loss and shortness of breath had a threefold increased risk of progression or death (hazard ratio [HR] = 3.06, 95% CI = 1.88 to 4.98; P < .001) and that those with high levels of both appetite loss and work limitations had a fivefold increased risk of death (HR = 5.60, 95% CI = 3.27 to 9.57; P < .001)-compared with those with neither risk category.

CONCLUSIONS

We found no evidence of a benefit of ipilimumab added to nivolumab compared with nivolumab alone for QOL in S1400I. A risk model identified patients at high risk of poor survival, demonstrating the prognostic relevance of baseline patient-reported outcomes even in those with previously treated advanced cancer.

Impact of low versus negative estrogen/progesterone receptor status on clinico-pathologic characteristics and survival outcomes in HER2-negative breast cancer

Triple-negative breast cancer (TNBC) is classically defined by estrogen receptor (ER) and progesterone receptor (PR) immunohistochemistry expression <1% and absence of HER2 amplification/overexpression. HER2-negative breast cancer with low ER/PR expression (1–10%) has a gene expression profile similar to TNBC; however, real-world treatment patterns, chemotherapy response, endocrine therapy benefit, and survival outcomes for the Low-ER group are not well known. 516 patients with stage I-III HER2-negative breast cancer and ER/PR expression ≤10% who were enrolled in a multisite prospective registry between 2011 and 2019 were categorized on the basis of ER/PR expression. TNBC (ER and PR < 1%) and Low-ER (ER and/or PR 1–10%) groups comprised 87.4% (n = 451) and 12.6% (n = 65) of patients, respectively. Demographic, clinical, and treatment characteristics, including prevalence of germline BRCA1/2 mutation, racial and ethnic distribution, and chemotherapy use were not different between TNBC and Low-ER groups. No difference was observed in recurrence-free survival (RFS) and overall survival (OS) between TNBC and Low-ER groups (3-year RFS 82.5% versus 82.4%, respectively, p = 0.728; 3-year OS 88.0% versus 83.4%, respectively, p = 0.632). Among 358 patients receiving neoadjuvant chemotherapy, rates of pathologic complete response were similar for TNBC and Low-ER groups (49.2% vs 51.3%, respectively, p = 0.808). The HER2-negative Low-ER group is often excluded from TNBC clinical trials assessing novel treatments (immunotherapy and antibody-drug conjugates), thus limiting efficacy data for newer effective therapies in this group. Given that HER2-negative Low-ER disease displays clinical characteristics and outcomes similar to TNBC, inclusion of this group in TNBC clinical trials is encouraged.

Acute Hemolytic Anemia Caused by Loxoscelism Treated With Plasmapheresis: A Case Report

The bite of a brown recluse spider (Loxosceles reclusa) is usually associated with skin necrosis; however, it can lead to more significant morbidity including acute hemolytic anemia, rhabdomyolysis, disseminated intravascular coagulopathy and death. Here we highlight a case using plasmapheresis as treatment for acute hemolytic anemia caused by the bite of a brown recluse spider. A 49-year-old male presented to the emergency room 5 days after suffering a spider bite due to worsening symptoms. He had worsening pain at the site of the bite, diffuse body myalgias, darkening of his urine, chills, and shortness of breath. Hematology was consulted to assist in the management of hemolytic anemia refractory to multiple blood transfusions, worsening acute kidney failure requiring hemodialysis, and concern for impending death. After a literature review suggesting plasmapheresis may be beneficial in this scenario, the case was discussed with the local blood bank, and plasmapheresis was initiated. The patient underwent plasmapheresis with albumin for 2 days and the patient’s hemoglobin improved and stabilized. Therapy of loxoscelism is directed at limiting the dermatonecrosis at the site of the envenomation and in cases of systemic illness supportive care is recommended. Therapeutic plasma exchange has been shown efficacious in treating snake envenomation, but there are limited data detailing its use for brown recluse spider envenomation. Here we present a case to highlight the benefit of plasmapheresis in a patient with acute hemolytic anemia secondary to a brown recluse spider bite.

Impact of Psychological Distress on Treatment Timeliness in Oncology Patients at a Safety-Net Hospital

BACKGROUND

Psychological distress is common in patients with cancer. Distress can affect patients' engagement with treatment. We examined the relationship between psychological distress and treatment timeliness in a sample of adult oncology patients at a safety-net hospital.

METHODS

A retrospective review was conducted of all patients screened for distress at a first outpatient oncology visit between March 1, 2014, and December 31, 2015 (n=500). The analytic sample (n=96) included patients with a new cancer diagnosis and a curative-intent treatment plan for lymphoma (stage I-IV), solid tumor malignancy (stage I-III), or head and neck cancer (stage I-IVb). Distress was measured using the Hospital Anxiety and Depression Scale. Using Poisson regression, we determined the effects of depression and anxiety on treatment timeliness. Patient age, sex, race/ethnicity, insurance type, cancer site, and cancer stage were included as covariates.

RESULTS

Mean patient age was 54 years. The median treatment initiation interval was 28 days. Clinically significant anxiety was present in 34% of the sample, and clinically significant depression in 15%. Greater symptom severity in both anxiety and depression were associated with a longer treatment initiation interval after controlling for demographics and disease factors. The average days to treatment (DTT) was 4 days longer for patients with elevated anxiety scores and for those with elevated depression scores compared with those without. Overall survival was not associated with anxiety, depression, or DTT.

CONCLUSIONS

In this safety-net patient sample, greater psychological distress was associated with slower time to treatment. As of writing, this is a new finding in the literature, and as such, replication studies utilizing diverse samples and distress measurement tools are needed.

Abstract PS6-04: Impact of low versus negative estrogen/progesterone receptor status on clinico-pathologic characteristics and survival outcomes in HER2 negative breast cancer

Background: Triple negative breast cancer is defined by lack of expression of ER/PR (immunohistochemistry expression &lt;1%) and absence of HER2 gene amplification. However, data regarding endocrine therapy benefit in patients with low levels (1-10%) of ER/PR expression are lacking. Furthermore, gene expression studies show tremendous similarities between HER2 negative tumors with low and negative ER/PR status. Accordingly, the 2020 ASCO/CAP guideline designates that ER expression of 1-10% be reported as a distinct “ER low positive” category. Utilizing data from a prospective registry, the aim of this study was to determine the impact of low versus negative ER/PR status on clinico-pathologic characteristics and survival outcomes in patients with HER2 negative breast cancers. Methods: 516 subjects with stage I-III HER2 negative breast cancer and ER/PR IHC ≤10% were enrolled in an IRB-approved multisite prospective registry between 2011 and 2019. Demographic, clinical, pathologic, and treatment information was collected, and patients were followed for recurrence and survival. Patients were categorized according to ER/PR expression into two groups: TNBC (ER and PR &lt;1%) and Low-ER (ER and/or PR 1-10%). Recurrence free survival (RFS) and overall survival (OS) were estimated according to the Kaplan-Meier method and compared among groups by log-rank test, followed by Cox regression analysis. Results: TNBC and Low-ER groups comprised 451/516 (87.4%) and 65/516 (12.6%) patients, respectively. Demographic, clinical, pathologic, and treatment characteristics of the two groups are described in Table 1. Median follow-up was 39 months. Three-year RFS was 82% for both TNBC and Low-ER groups (p=0.70). Three-year OS was 88% and 83% for TNBC and Low-ER groups, respectively (p=0.63). Twenty percent of patients in the Low-ER group received adjuvant endocrine therapy, and endocrine therapy use did not impact outcomes in the Low-ER group (RFS: p=0.32; OS: p=0.88). On multivariate analysis, T stage, nodal status, and age significantly impacted RFS (T stage 3/4 vs 1/2, HR=2.7, p&lt;0.001; nodal status positive vs negative, HR=2.4, p&lt;0.001; age above vs below median, HR=1.8, p=0.006) and OS (T stage 3/4 vs 1/2, HR=3.6, p&lt;0.001; nodal status positive vs negative, HR=2.8, p&lt;0.001; age above vs below median, HR=1.026, p=0.01). For patients who received neoadjuvant chemotherapy, achievement of pathological complete response (pCR) was associated with superior RFS (3-year RFS of 95% and 67% in those with and without pCR, respectively, HR=0.18, p&lt;0.001). Conclusions: Patients with TNBC and Low-ER HER2 negative breast cancer present with similar clinico-pathologic characteristics, including prevalence of germline BRCA1/2 mutation. Prognosis and rate of pCR (with neo-adjuvant chemotherapy) in patients with Low-ER HER2 negative breast cancer is similar to those with TNBC. The role and efficacy of adjuvant endocrine therapy in patients with Low-ER breast cancer is unclear. These findings support consideration for inclusion of patients with Low-ER disease along with TNBC for future clinical trial eligibility and planning.

Table 1. Demographic, clinical, pathologic, and treatment characteristicsCharacteristics - N (%)All N=516TNBC (ER & PR &lt;1%) n=451Low-ER (ER or PR 1-10%) n=65pAge at diagnosis, years - median (range)53 (23-97)54 (23-97)51 (28-76)0.61RaceWhite386 (75%)335 (74%)51 (79%)0.69Black101 (20%)89 (20%)12 (19%)Asian8 (2%)8 (2%)0 (0%)Menopausal statusPre214 (42%)181 (41%)33 (51%)0.25Post295 (58%)263 (59%)32 (49%)Histological gradeI2 (0.4%)2 (0.4%)0 (0%)0.82II86 (17%)76 (17%)10 (15%)III428 (83%)373 (83%)55 (85%)T stageT1-2446 (87%)388 (87%)58 (89%)0.56T3-467 (13%)60 (13%)7 (11%)N statusPositive177 (34%)158 (35%)19 (29%)0.36Negative339 (66%)293 (65%)46 (71%)TNM stageI179 (35%)150 (33%)29 (44%)0.10II263 (51%)232 (52%)31 (48%)III74 (14%)69 (15%)5 (8%)Germline BRCA1/2 mutationYes70 (14%)64 (14%)6 (9%)0.53No357 (69%)309 (69%)48 (74%)Unknown89 (17%)78 (17%)11 (17%)ChemotherapyNeoadjuvant357 (69%)318 (71%)39 (60%)0.23Adjuvant147 (29%)123 (27%)24 (37%)None12 (2%)10 (2%)2 (3%)Surgery typeMastectomy308 (60%)275 (61%)33 (51%)0.10Lumpectomy205 (40%)173 (39%)32 (49%)Adjuvant endocrine therapyYes20 (4%)7 (2%)13 (20%)&lt;0.001No496 (96%)444 (98%)52 (80%)pCR (in patients with neoadjuvant chemotherapy, n=357)176 (49%)157 (49%)19 (49%)0.94

Citation Format: Rachel Yoder, Bruce F Kimler, Joshua M Staley, Kelsey Schwensen, Yen Y Wang, Karissa Finke, Anne O'Dea, Lauren Nye, Manana Elia, Gregory Crane, Richard McKittrick, Robert Pluenneke, Sheshadri Madhusudhana, Larry Beck, Roberto Rodriguez, Anuj Shrestha, Larry Corum, Mark Marsico, Andrew K Godwin, Qamar Khan, Priyanka Sharma. Impact of low versus negative estrogen/progesterone receptor status on clinico-pathologic characteristics and survival outcomes in HER2 negative breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-04.

A Case Report of Acquired Factor X Deficiency in a Patient With Multiple Myeloma

Multiple myeloma is a plasma cell neoplasm characterized by clonal proliferation of immunoglobulin producing terminally differentiated B cells. Classically patients are described to present with bone pain, hypercalcemia, anemia, and/or renal impairment. A less described clinical manifestation related to the myeloma is acquired coagulation abnormalities including paraprotein interfering with the coagulation cascade or exhibiting specific antibody activity. Factor X deficiency is reported in patients with secondary amyloidosis. We describe a patient who presented with bleeding tendency and an abnormal prothrombin and activated partial thromboplastin times (PT/PTT) due to factor X deficiency. A thorough workup revealed the diagnosis of multiple myeloma with the presence of monoclonal lambda light chain restricted plasma cells with qualifying end-organ damage without evidence of amyloidosis. Prior to the ultimate diagnosis, the patient succumbed to septic shock and acute respiratory distress syndrome due to Streptococcus Pneumonia infection.

Randomized Phase II Trial of Anthracycline-free and Anthracycline-containing Neoadjuvant Carboplatin Chemotherapy Regimens in Stage I-III Triple-negative Breast Cancer (NeoSTOP)

PURPOSE

Addition of carboplatin (Cb) to anthracycline chemotherapy improves pathologic complete response (pCR), and carboplatin plus taxane regimens also yield encouraging pCR rates in triple-negative breast cancer (TNBC). Aim of the NeoSTOP multisite randomized phase II trial was to assess efficacy of anthracycline-free and anthracycline-containing neoadjuvant carboplatin regimens.

PATIENTS AND METHODS

Patients aged ≥18 years with stage I-III TNBC were randomized (1:1) to receive either paclitaxel (P) weekly × 12 plus carboplatin AUC6 every 21 days × 4 followed by doxorubicin/cyclophosphamide (AC) every 14 days × 4 (CbP → AC, arm A), or carboplatin AUC6 + docetaxel (D) every 21 days × 6 (CbD, arm B). Stromal tumor-infiltrating lymphocytes (sTIL) were assessed. Primary endpoint was pCR in breast and axilla. Other endpoints included residual cancer burden (RCB), toxicity, cost, and event-free (EFS) and overall survival (OS).

RESULTS

One hundred patients were randomized; arm A (n = 48) or arm B (n = 52). pCR was 54% [95% confidence interval (CI), 40%-69%] in arm A and 54% (95% CI, 40%-68%) in arm B. RCB 0+I rate was 67% in both arms. Median sTIL density was numerically higher in those with pCR compared with those with residual disease (20% vs. 5%; P = 0.25). At median follow-up of 38 months, EFS and OS were similar in the two arms. Grade 3/4 adverse events were more common in arm A compared with arm B, with the most notable differences in neutropenia (60% vs. 8%; P < 0.001) and febrile neutropenia (19% vs. 0%; P < 0.001). There was one treatment-related death (arm A) due to acute leukemia. Mean treatment cost was lower for arm B compared with arm A (P = 0.02).

CONCLUSIONS

The two-drug CbD regimen yielded pCR, RCB 0+I, and survival rates similar to the four-drug regimen of CbP → AC, but with a more favorable toxicity profile and lower treatment-associated cost.

Do socioeconomic factors really have an impact on early detection of hepatocellular carcinoma and colorectal cancer?

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Background: Improving surveillance in hepatocellular carcinoma (HCC) and colorectal cancer (CRC) is an important topic in the field of gastroenterology and oncology due to significant benefit associated with early detection and better outcomes. Multiple studies have been undertaken to assess the association between the socioeconomic status of the population and adherence to HCC/CRC screening. Most of these studies used self-reporting surveys and faced limitations due to reporting bias. We aimed to assess the relevance of socioeconomic factors in the diagnosis of HCC and CRC in Jackson County, Missouri by means of a census-based survey. Methods: We retrospectively studied 190 HCC and 690 CRC cases at our institution using a census-based analysis, which consisted of geocoding home addresses of patients and then attaching block level census variables for household occupancy, education level and household income. Statistical analysis was performed using Cox proportional hazard model and ordinal logistic regressions. Results: We did not find a statistically significant association between socioeconomic factors and adherence to surveillance guidelines for HCC and CRC. USPSTF-2019 guidelines for CRC and AASLD-2018 guidelines for HCC screening were taken into account. Variables that were analyzed included high school education or better (p = 0.5), four-person households with one or more workers (p = 0.08) and income less than 25 thousand dollars (p = 0.58). Study results were risk adjusted for age, race, and gender. Separate ordinal logistic regression analysis was done to also adjust for the stage at the time of eventual cancer diagnosis, no statistically significant result was obtained. Conclusions: Our study showed no association between demographic variables and participation in HCC or CRC surveillance. The study is limited by a relatively small sample size confined to local patients seen at our institution. Multicenter census-based surveys and meta-analyses need to be conducted to determine whether socioeconomic factors really have an appreciable impact on early screening and detection of HCC and CRC.

A Case of Rituximab-Induced Acute Thrombocytopenia in a Patient with Splenic Marginal Zone Lymphoma and Chronic Hepatitis C Virus Infection

Patient: Female, 46

Final Diagnosis: Rituximab induced acute thrombocytopenia

Symptoms: Abdominal discomfort

Medication:—

Clinical Procedure: —

Specialty: Hematology

Results of randomized phase II trial of neoadjuvant carboplatin plus docetaxel or carboplatin plus paclitaxel followed by AC in stage I-III triple-negative breast cancer (NCT02413320)

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Background: Addition of neoadjuvant carboplatin (Cb) to paclitaxel (T) followed by doxorubicin + cyclophosphamide (AC) improves pathologic complete response (pCR) rate compared to T/AC in TNBC. An anthracycline-free regimen of Cb plus docetaxel (D) also yields high pCR rates in TNBC, and patients achieving pCR with this regimen demonstrate excellent 3-year outcomes without adjuvant anthracycline. This study was designed to compare the efficacy of neoadjuvant regimens CbT→AC and CbD in TNBC. Methods: In this multicenter study, eligible patients with stage I–III TNBC were randomized (1:1) to either paclitaxel 80 mg/m2 every week X 12 + carboplatin (AUC 6) every 3 weeks X 4, followed by doxorubicin 60 mg/m2 + cyclophosphamide 600 mg/m2 every 2 weeks X 4 (CbT→AC, Arm A), or to carboplatin (AUC 6) + docetaxel (75 mg/m2) every 21 days X 6 cycles (CbD, Arm B). The primary endpoint was pCR (no evidence of invasive tumor in the breast and axilla). The two regimens were compared for differences in pCR, residual cancer burden (RCB), treatment delivery, and toxicity. Results: Between 2015 and 2018, 100 patients were randomized; 48 to Arm A and 52 to Arm B. Median age was 52 years, median tumor size was 2.7 cm, 30% were lymph node-positive and 17% carried a BRCA1/2 mutation. Baseline demographic and tumor characteristics were balanced between two arms. pCR was 55% (95%CI: 41%-59%) in Arm A and 52% (95%CI: 39%-65%) in Arm B, p =0.84. RCB 0+1 rate was 67% in both arms. Grade 3/4 adverse events were more common in Arm A compared to Arm B (73% vs 21%, p < 0.0001), with most notable differences in rates of G3/4 neutropenia (Arm A = 60%, Arm B = 8%, p = 0.0001), febrile neutropenia (Arm A = 18%, Arm B = 0%, p = 0.0001), and G3/4 anemia (Arm A = 46%, Arm B = 4%, p = 0.0001). 81% of Arm A patients completed all 4 doses of AC and 4 doses of Cb, and 71% completed > 9 doses of T. 90% of Arm B patients completed all 6 doses of CbD (p = 0.034). Conclusions: The non-anthracycline platinum regimen of CbD yields pCR and RCB 0+1 rates similar to 4-drug regimen of CbTàAC, but with a more favorable toxicity profile and higher treatment completion rate. The CbD regimen should be further explored as a way to de-escalate therapy in TNBC. Clinical trial information: NCT02413320.

Impact of absolute lymphocyte count on prognosis of aggressive non-Hodgkin lymphoma

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Background: Multiple studies have attempted to identify parameters to predict prognosis and overall survival (OS) in Non-Hodgkin Lymphoma (NHL). Revised International Prognostic Index (R-IPI) is commonly used but does not capture all predictive risk factors in the Rituximab era. Low absolute lymphocyte count (ALC) on follow up after first line therapy has been reported to predict relapse. The prognostic value and exact cut off for low ALC at diagnosis is not known. We aimed to investigate whether ALC at time of diagnosis is an independent predictor for OS in aggressive NHL. Methods: We retrospectively evaluated patients with aggressive NHL treated at our center from 1/2000 to 12/2016 with at least 2 year longitudinal follow up after diagnosis. We retrieved data for baseline characteristics including age, sex, Ann Arbor stage, R-IPI score, HIV status, histopathological diagnosis (Diffuse Large B Cell Lymphoma (DLBCL), Burkitt′s lymphoma, Follicular Lymphoma Grade IIIB, high-grade B cell lymphoma), type of chemotherapy and clinical response. Patients were divided into four subgroups based on ALC at diagnosis: < 500, 501-1000, 1001-1500 and > 1500X109/L. Statistical analysis was done using REDCAP and Stata v13. Results: A total of 92 patients were identified. The average age at diagnosis was 53.4 years, 63% were male and 73.5% were diagnosed with DLBCL. Per R-IPI score, 16.3% were high risk, 31.3% were high intermediate risk, 22.5% low intermediate risk and 30% were low risk. The median OS for patients with ALC < 500 x109/L (5.4%) was 1.5 years, ALC 501-1000 (38%) was 2.3 years, ALC 1001-1500 (23.9%) was 4.25 years and ALC > 1500 (32.6%) was 5.2 years. On multivariate analysis this difference was not statistically significant due to small sample size. Conclusions: We found that low ALC at diagnosis trended towards worse OS in aggressive NHL but did not reach statistical significance on multivariate analysis. Our study is limited by retrospective nature and sample size. Multicenter studies need to be done to validate these results. Studies are also needed to know the exact cut off for low ALC. [Table: see text]

Zieve's Syndrome: An Under-reported Cause of Anemia in Alcoholics

Anemia is a common finding in alcoholics. It is often multifactorial and caused by a combination of liver dysfunction, ineffective erythropoiesis, and poor nutrition. Zieve’s syndrome (ZS) is a clinical syndrome that presents with a triad of jaundice, hemolytic anemia, and hyperlipidemia secondary to alcohol use. Herein, we present a case of a 58-year-old male with a history of liver cirrhosis who presented after a fall due to binge drinking and was found to have severe anemia. Workup was consistent with hemolytic anemia with no source of active bleeding. The patient was managed with supportive treatment and blood transfusions which improved his anemia. However, given his advanced liver disease, he developed encephalopathy and subsequently severe aspiration pneumonia. He died 18 days after admission.

A randomized clinical trial of counseling and nicotine replacement therapy for treatment of African American non-daily smokers: Design, accrual, and baseline characteristics

BACKGROUND

Non-daily smokers (NDS) who smoke on some but not all days are a growing subset of United States (US) tobacco users. Racial/ethnic minorities are more likely to be NDS. African American NDS have strikingly high levels of nicotine and carcinogen exposure, making treatment of this high risk group a priority.

METHODS

The current study is one of three ongoing federally-funded clinical trials of NDS and, to our knowledge the only RCT focused on racial/ethnic minority NDS. The design has been guided by input from Patient and Stakeholder Advisory Panels who helped develop the research questions, design the intervention, and select the outcomes. The objective is to compare the effectiveness of smoking cessation counseling alone (C) or smoking cessation counseling plus participant's choice of nicotine replacement therapy (NRT; C + NRT) for African American NDS. Two-hundred seventy-eight African American NDS will be randomized in a 2:1 fashion to C + NRT or C. All participants receive five sessions of smoking cessation counseling; those randomized to C + NRT receive their choice of nicotine gum, patch, and/or lozenge. Treatment in both groups lasts for 12 weeks. We hypothesize that C + NRT will be more effective than C on the primary outcome of biochemically-confirmed abstinence from smoking at week 12. Secondary aims will compare C + NRT and C on patient- and provider-desired outcomes including abstinence from smoking at week 26, change in biochemically-verified nicotine and carcinogen exposure, days abstinent, and treatment process measures (e.g., NRT use and side effects). Predictors of abstinence will also be explored.

DISCUSSION

Findings will illuminate effective treatment options for African American NDS and contribute to development of evidence-based guidelines for treating the 8.9 million US adult NDS for whom no guidelines currently exist.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02244918.

Trastuzumab-associated Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome that presents with neurological manifestations, including seizures, headache, or confusion, and is associated with posterior cerebral white matter edema on imaging. PRES is typically a benign and reversible condition. However, PRES can be fatal or associated with permanent deficits. Numerous conditions are associated with PRES, including hypertensive encephalopathy, renal diseases, and cytotoxic or immunosuppressant drugs. Recently, many case reports described the association between PRES and chemotherapeutic agents. However, trastuzumab-associated PRES is rarely reported. Herein, we report a case of a 51-year-old female with a history of metastatic gastric cancer who developed seizures while being treated with trastuzumab, and neuroimaging confirmed the diagnosis of PRES.

'Blastoid' variant of Burkitt lymphoma with additional partial 1q tetrasomy

Burkitt lymphoma is cytogenetically characterized by t(8;14)(q24;q32) translocation, sometimes accompanied by additional cytogenetic abnormalities. These abnormalities usually result in more aggressive clinical presentation and morphology of the disease. The current report presens a case of Burkitt lymphoma with t(8;14)(q24;q32) accompanied by partial tetrasomy of chromosome 1(47,XY,+1,i(1)(q10),t(8;14)(q24;q32)[2]/46,XY[18]). The patient was a 59-year-old male who presented with abdominal pain, leukocytosis and tumor lysis syndrome. No lymphadenopathy was noted. Cerebrospinal fluid analysis revealed atypical lymphocytes. A peripheral blood smear revealed tumor cells exhibiting distinct ‘blastoid’ morphology: Prominent nucleoli, basophilic cytoplasm, occasional cytoplasmic vacuoles. Flow cytometry demonstrated B cells expressing cluster of differentiation (CD)10 and cytoplasmic kappa light chain restriction without surface expression of immunoglobulins and CD20. A bone marrow biopsy revealed hematopoiesis, with a 90% replacement with atypical lymphocytes. The patient was treated with chemotherapy. Following the first cycle of treatment, the patient developed neutropenic fever, bacteremia and died a few days later. Gain of chromosome 1q in addition to characteristic for Burkitt lymphoma t(8;14)(q24;q32) resulted in immature ‘blastoid’ morphology and the immunophenotype of tumor cells, leukemic presentation without lymph node involvement and a highly aggressive clinical course.

Abstract P4-10-06: Influence of older age on triple negative breast cancer (TNBC) clinical-pathological characteristics and outcomes

Background: The impact of age at diagnosis on clinical presentation and treatment delivery for triple negative breast cancer (TNBC) is unclear. Utilizing data from a prospective registry, the aim of this study was to further elucidate the age-dependent correlation between TNBC clinical-pathological features, and the implications of age-bias on treatment delivery and prognosis.

Methods: 480 subjects with stage I-III TNBC were enrolled in an IRB approved multisite prospective registry between 2011 and 2016. Clinical, demographic, treatment information was collected and patients were followed for recurrence and survival. Patients were categorized as older (&gt;60 years) or younger groups (&lt;60 years). Recurrence free survival (RFS) and overall survival (OS) were estimated according to the Kaplan-Meier method and compared among groups by log-rank test.

Results: 145 (30%) of 480 TNBC patients were older (&gt; 60 years) at time of diagnosis. Compared to younger patients, older patients were more likely to present with screen detected vs symptomatic cancer (47% vs 25% p=&lt;0.001), more likely to have node negative cancer (71% vs 61% p=0.030), stage I disease (42% vs 28% p=0.003), and low level (1-10%) ER or PR positivity (19% vs 12% p=0.046). Compared to the younger patients, older patients were less likely to have a BRCA1/2 mutation (6% vs 23% p=0.0002) but more likely to have a prior history of hormone positive breast cancer (7% vs 1% p=0.0002). Compared to younger counterparts, older patients were less likely to receive neo/adjuvant chemotherapy (93% vs 99% p=0.0006), and less likely to receive &gt; 4 cycles of neo/adjuvant chemotherapy (61% vs 78%, p=0.0003). Three year RFS for the entire cohort was 80% and was identical for older and younger patients at 80%. Three year OS for the entire cohort was 87% and was similar for older and younger patients. On multivariable analysis only tumor size and nodal status significantly impacted RFS.

Conclusions: A significant fraction (30%) of TNBC patients are older (&gt; 60 years) at time of diagnosis. Despite presenting a with more favorable disease stage, older TNBC patients did not demonstrate better outcomes compared to the higher risk younger patients. The underlying reasons for this observation may be tumor biology differences between older and younger TNBC patients or perhaps could be related to underutilization of appropriate systemic chemotherapy (39% of older patients received &lt; 4 cycles of chemotherapy). Further studies are warranted on this subject.

Citation Format: Mina A, Lehn C, Wang YY, Klemp JR, O'Dea AP, Elia M, Hoffmann M, Crane G, Sheehan M, Madhusudhana S, Jensen RA, Godwin AK, Khan QJ, Kimler BF, Sharma P. Influence of older age on triple negative breast cancer (TNBC) clinical-pathological characteristics and outcomes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-06.

Two for One: B-Cell Lymphomas with Features of Marginal and Follicular Lymphomas

Low-grade follicular lymphomas are genetically characterized by the translocation t(14; 18)(q32;q21) with BCL2 gene rearrangements. Marginal zone lymphomas are often associated with translocations or transcriptional deregulations of the MALT gene. We report 2 cases of lymphomas which harbor both the t(14;18)(q32;q21) translocation and MALT gene upregulation. Patients presented with numerous circulating atypical lymphocytes. Lymph node biopsy in both cases on HE staining demonstrated vague nodularity readily highlighted by CD10, CD23, or BCL6. Staining with CD20 and BCL2 demonstrated monotonous diffuse effacement of normal architecture with tumor cells without obvious follicular structures. Morphologically, tumor cells were consistent with centrocytes. Bone marrow biopsy demonstrated a combined peritrabecular and interstitial distribution of the tumor cells. These cases present substantial difficulties for diagnosis and classification. Clinical and morphological features were mostly consistent with follicular lymphoma, with a few features more often seen in marginal zone lymphomas (leukemic presentation, no CD10 in circulating cells, interstitial location of tumor cells in bone marrow); therefore, these cases were finally classified as follicular lymphoma grade I. Both patients were treated with standard chemotherapy regimens for follicular and nongastric MALT lymphomas with a good response to date.

Assessment of the impact of the Hospital Anxiety and Depression Scale on the initiation of treatment in newly diagnosed cancer patients in a safety-net hospital

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Background: Distress is a universal symptom in oncologic patients which negatively impact the quality of life and survival. It interferes with the ability to cope with the diagnosis and is a risk factor for non-adherence with treatment. The Hospital Anxiety and Depression Scale (HADS), is used at our institution for distress screening. The aim of our study is to assess the impact of distress, measured by the HADS score, on initiation of treatment in newly diagnosed cancer patients. Methods: We conducted a retrospective chart review of patients with a new diagnosis of cancer, between March 1st, 2014 and December 31st, 2015; who had been evaluated for distress at their first oncology clinic visit. We included only patients who were treated with chemotherapy or chemoradiation, with curative intent. Poisson regression analysis was conducted to investigate the relationship between HADS to treatment initiation while including age, sex, race, insurance status, cancer type, and stage as covariates in the model. Results: A total of 101 patients met the inclusion criteria. The mean age was 54 years, 63% were female and 37% were male. The majority were Caucasians (53%), followed by African-Americans (36%). 56% of the population had Medicaid, and 26% had Medicare and private insurance. The most common cancers were – breast (30%), gastrointestinal (20%), gynecologic (15%) and lung (11%). 64% received chemotherapy and 36% were treated with chemoradiation. We grouped patients into 3 categories based on the HADS score – category 1 with score ≤7 (28%), category 2 with score 8-10 (17%) and category 3 with score ≥11 (55%). The median time to treatment initiation was 28 days. Multivariate Poisson regression analysis did not show any correlation between the HADS score and treatment initiation. Subscales analyses showed that higher depression scores correlate with a delay in treatment initiation (p-value 0.01), while the anxiety scores had no influence (p-value 0.57). Conclusions: In our study, the initial total HADS score did not affect the treatment initiation. Interestingly, depression had an influence on the initiation of treatment in newly diagnosed cancer patients.

Searching for cures: Inner-city and rural patients' awareness and perceptions of cancer clinical trials

Fewer than 5% of cancer patients participate in clinical trials, making it challenging to test new therapies or interventions for cancer. Even within that small number, patients living in inner-city and rural areas are underrepresented in clinical trials. This study explores cancer patients' awareness and perceptions of cancer clinical trials, as well as their perceptions of patient-provider interactions related to discussing cancer clinical trials in order to improve accrual in cancer clinical trials. Interviews with 66 former and current in inner-city and rural cancer patients revealed a lack of awareness and understanding about clinical trials, as well as misconceptions about what clinical trials entail. Findings also revealed that commercials and television shows play a prominent role in forming inner-city and rural patients' attitudes and/or misconceptions about clinical trials. However, rural patients were more likely to hold unfavorable views about clinical trials than inner-city patients. Patient-provider discussions emerged as being crucial for increasing awareness of clinical trials among patients and recruiting them to trials. Findings from this study will inform communication strategies to enhance recruitment to cancer clinical trials by increasing awareness and countering misconceptions about clinical trials.

Abstract P5-16-02: Pathological complete response is associated with excellent outcomes in BRCA mutation associated triple negative breast cancer

Introduction: Pathological complete response (pCR) in unselected triple negative breast cancer (TNBC) is associated with excellent long-term survival. However, controversy remains as to whether pCR in BRCA mutation associated (BRCA[+]) TNBC is predictive of improved long-term outcome. A recent study suggests that pCR was not a surrogate for outcomes in BRCA1 associated TNBC. All of the patients in this study harbored an Ashkenazi Jewish founder BRCA1 mutation and the majority of mutation carriers underwent lumpectomy. Impact of pCR as it relates to BRCA status in a larger, heterogeneous TNBC cohort treated in a contemporary time frame is not known.

Aim: Evaluate and compare the prognostic impact of pCR as it relates to the BRCA mutation status in patients enrolled in a prospective multisite TNBC registry.

Methods: 453 patients with stage I-III TNBC were enrolled within a multisite registry between 2011- 2015, out of which 173 received neoadjuvant chemotherapy (NAC) and also underwent germline BRCA testing. pCR in the breast and axilla was evaluated and patients were followed for reoccurrence and survival. Recurrence free survival (RFS) was estimated according to the Kaplan-Meier method and compared among groups with log-rank statistic.

Results: For the 173 eligible patients the median age was 49 years; African-American:14%; median tumor size:3 cm; 42%:Lymph node positive; and 18% (32/173) demonstrated BRCA mutation (BRCA1=28, BRCA2=4). All patients received anthracycline and/or taxane based NAC. pCR rates for BRCA[+] and wild type (BRCA[-]) patients was 72% and 46% respectively (p=0.01). 97% of BRCA[+] and 42% of BRCA[-] patients underwent bilateral mastectomy (p=0.001). The three year RFS was 92% and 81% in BRCA[+] and BRCA[-] patients, respectively (p=0.18). Attainment of pCR was associated with excellent 3 year RFS of 95% and 97% in BRCA[+] and BRCA[-] patients, respectively (p=0.85). Among BRCA[-] patients lack of pCR was associated with significantly worse 3 year RFS (70% RFS in patients without pCR, compared to 97% in patients with pCR; p=0.001). Among BRCA[+] patients lack of pCR was associated with numerically lower but not statistically significant worse 3 year RFS (83% RFS in patients without pCR, compared to 95% in patients with pCR; p=0.41). On multivariable Cox regression analysis, only stage III disease was associated with higher risk of relapse (p&lt;0.001).

Conclusions: Our observation of higher pCR in BRCA-carriers compared to wild-type TNBC patients is consistent with previously published literature. In this contemporary cohort of TNBC patients for whom the majority of BRCA[+] patients underwent bilateral mastectomy, attainment of pCR carried an excellent prognosis in both BRCA[+] and BRCA[-] patients. On the other hand, BRCA[+] patients who do not attain pCR may have better outcomes compared to BRCA[-] patients without pCR. Further research to explore the underlying biological mechanisms involved in tumor response and relapse in BRCA[+] and BRCA[-] TNBC patients is needed. Furthermore, given these observations, germline BRCA mutation status should be used as a stratification variable in studies evaluating pCR and long term outcomes with investigational therapies in TNBC.

Citation Format: Prochaska LH, Godwin AK, Kimler BF, Lehn C, Klemp JR, O'Dea A, Elia M, Hoffmann MS, Crane G, McKittrick R, Sheehan M, Graff SL, Madhusudhana S, Khan QJ, Jensen RA, Sharma P. Pathological complete response is associated with excellent outcomes in BRCA mutation associated triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-02.

Impact of statin use on cancer recurrence and mortality in breast cancer: A systematic review and meta-analysis

Statins have shown antineoplastic properties in preclinical studies with breast cancer cells. They inhibit the enzyme "HMG CoA reductase" and the expression of this enzyme in cancer cells has been implicated as a favorable prognostic factor in patients with breast cancer. After a search of MEDLINE and Embase from inception through November 2015, 817 abstracts were reviewed to identify studies that described an association between statin use and outcomes in breast cancer. A total of 14 studies which included 75,684 women were identified. In a meta-analysis of 10 studies, statin use was associated with improved recurrence-free survival (RFS; HR 0.64; 95% CI 0.53-0.79, I(2)  = 44%). Furthermore, this RFS benefit appeared to be confined to use of lipophilic statins (HR 0.72; 95% CI 0.59-0.89) as hydrophilic statin use was not associated with improvement in RFS (HR 0.80; 95% CI 0.44-1.46). Statin users similarly showed improved overall survival in a meta-analysis with substantial heterogeneity (8 studies, HR 0.66; 95% CI 0.44-0.99, I(2)  = 89%). Statin users also had improved cancer-specific survival, although this relationship was measured with less precision (six studies, HR 0.70; 95% CI 0.46-1.06, I(2)  = 86%). In conclusion, breast cancer patients who use statins, or specifically, lipophilic statins show improved recurrence-free survival. Statin users also had improved overall survival and cancer-specific survival. These findings should be assessed in a prospective randomized cohort and the choice of statin, dose and biomarkers that may predict the efficacy of these drugs should be identified.

Abstract PD1-01: Impact of statin use on cancer recurrence and mortality in patients with breast cancer: A systematic review and meta-analysis

Background:

Statins have been described as having an association with a decreased risk of breast cancer. They have also shown antineoplastic properties in preclinical studies. Statins inhibit the enzyme 'HMG CoA reductase' and the expression of this enzyme in cancer cells has been implicated as an adverse prognostic factor in patients with breast cancer.

Methods:

We performed a systemic review of literature through April 2015 and utilized PubMed and Embase to identify studies that described an association between statin use and survival in breast cancer. Studies which did not report a comparison of survival using Kaplan-Meier curves were excluded. Summary hazard ratio (HR) with 95% confidence intervals (CI) was estimated using the random effects model, and heterogeneity was measured using the inconsistency index (I2).

Results:

After reviewing 637 abstracts, 12 studies which included a total of 87951 patients were identified and data was extracted. 8 studies provided a summary statistic for the association of statins with recurrence-free survival (RFS) in patients with breast cancer and were included in a meta-analysis. Statin use was associated with improved RFS (N= 29729 patients, HR 0.66; 95% CI 0.53- 0.84) with moderate heterogeneity (I2= 48%). Furthermore, this survival benefit appeared to be confined to use of lipophilic statins (3 studies, HR 0.72; 95% CI 0.59- 0.89) as hydrophilic statin use was not associated with improvement in RFS (3 studies, HR 0.80; 95% CI 0.44- 1.46). A meta-analysis of 5 studies showed no significant association between the use of statins on breast cancer-specific survival (CSS) (N= 60686 patients, HR 0.71; 95% CI 0.49- 1.03, I2= 84%). We also found no association between statin use and overall survival (OS) (5 studies and 22283 patients, HR 0.83; 95% CI 0.58- 1.19, I2= 62%).

Conclusions:

Statin use, or more specifically, lipophilic statin use is associated with an improved recurrence-free survival for patients with breast cancer. However, there was no effect of statin use on either cancer-specific survival or overall survival. These benefits need to be assessed in a prospective randomized cohort and the choice of statin, dose and biomarkers that may predict the efficacy of these drugs will need to be identified.

Characteristics of included studiesNameYearCountryImpact on RFSImpact on CSSImpact on OSSample SizeMedian follow-up (in years)Desai2015USANA0.59 [0.32, 1.06]NA7,88311.5Cardwell2015UKNA0.84 [0.68, 1.04]0.84 [0.72, 0.97]17,8805.7Murtola2014FinlandNA0.46 [0.38, 0.55]NA31,1143.25Boudreau2014USA0.78 [0.56, 1.08]NANA4,2166.3Sendur2014TurkeyP 0.004P 0.005P = 0.0051,1724Brewer2013USA0.49 [0.28-0.84]0.85 [0.46, 1.57]0.80 [0.43, 1.49]724NANickels2013Germany0.83 [0.54,1.24]0.89 [0.52, 1.49]1.21 [0.87, 1.69]3,085*5.3Zeichner2013USA1.42 [0.42, 4.81]NA1.5 [0.07, 32.02]3003.5Chae2011USA0.40 [0.24, 0.67]NANA7034.5Ceacareanu2011USA0.27 [0.10, 0.71]NA0.23 [0.08, 0.66]2942.5Ahern2011Denmark0.80 [0.64, 1.00]NANA18,7696.8Kwan2008USA0.67 [0.39, 1.13]NANA1,8115*= sample size for RFS: 2912, Abbreviations: RFS: recurrence-free survival, CSS: cancer-specific survival, OS: overall survival (expressed in hazard ratio and 95% confidence intervals)

Citation Format: Manthravadi S, Shrestha A, Madhusudhana S. Impact of statin use on cancer recurrence and mortality in patients with breast cancer: A systematic review and meta-analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD1-01.

The t(14;18)(q32;q21) with extra MYC signal - is it a gray zone lymphoma?

Double-hit lymphomas (DHL) are defined as B-cell lymphoma with a chromosomal breakpoint affecting the MYC/8q24 locus in combination with rearrangement at (14;18)(q32;q21). We recently observed three cases of B-cell lymphoma with an extra intact MYC signal in association with the t(14;18)(q32;q21) translocation. The impact of an extra copy of MYC to the clinical course and prognosis of one patient with Diffuse Large B Cell Lymphoma (DLBCL) and two patients with Follicular Lymphoma (FL) was evaluated. Flow cytometry in all cases demonstrated lambda- or kappa-light chain restricted CD20 and CD10 positive neoplastic B cells. FISH analysis was negative for MYC gene rearrangement but demonstrated an extra copy of intact MYC. Tissue sections displayed typical starry sky "gray zone" lymphoma morphology in case of DLBCL and FL morphology in cases 2 and 3, with high Ki67 labeling in all three cases. All patients responded well to initial chemotherapy although displayed variant outcome after initial remission. The patient with DLBCL deceased within a year of diagnosis while the other two patients with FL showed much better overall survival. Our limited experience showed that additional copy of intact MYC may be equivalent to "classic" DHL on the background of DLBCL with additional cytogenetic abnormalities, however isolated t(14;18)(q32;q21) translocation in combination with additional copy of intact MYC may demonstrate histology and clinical outcome more comparable with "classic" low grade follicular lymphoma, albeit with more aggressive morphology.

Evidence of BRAF V600E in indeterminate cell tumor and interdigitating dendritic cell sarcoma

BRAF V600E mutations have been reported in several histiocytic and dendritic cell neoplasms. In this case series, we report BRAF V600E-positive histiocytic and dendritic cell neoplasms in association with lymphomas and lymphoid proliferations. This is a review of cases with immunohistochemistry for BRAF V600E, with additional immunohistochemistry to categorize tumors. We report the first case of BRAF V600E-positive indeterminate cell tumor in association with angioimmunoblastic T-cell lymphoma. We also report a case of BRAF V600E-positive interdigitating dendritic cell sarcoma in a patient with positive B-cell polymerase chain reaction. It is unclear if these neoplasms developed as transdifferentiation of lymphoid neoplasms or if they developed independently. These cases illustrate the expanding spectrum of BRAF V600E-positive histiocytic and dendritic cell tumors and suggest that attention should be paid to lymphomas for possible coincident presentation of these disorders.

Switching between oral anticoagulants

Until about 4 years ago, warfarin was the only oral anticoagulant approved in the United States, and switching between oral anticoagulants has become an option since the emergence of the novel oral anticoagulants dabigatran, rivaroxaban, and apixaban. What are the reasons one may switch between the agents and how is this done? Discussed in this article are the 4 agents approved in the United States, their characteristics, reasons one may switch, and methods for conversion. After a thorough search of original trial data and recent expert review articles, we have summarized the most recent recommendations below and briefly discuss upcoming oral anticoagulants that show promise.

Current issues in the diagnosis and management of deep vein thrombosis

The diagnosis and management of deep vein thrombosis (DVT) is of high importance given that a DVT can progress to a life threatening pulmonary embolism (PE) if undetected. At the same time the treatment of DVT involves anticoagulation which can lead to fatal complications and hence accurate evaluation methods are needed to diagnose or rule out DVT. Diagnosis of DVT has evolved recently with the introduction of clinical prediction rules combined with d-dimer and compression ultrasonography (CUS). Multidetector CT venography and MR venography have been used for the conformation of the diagnosis. Therapy of DVT has also evolved with the introduction of new anticoagulant agents. However much research needs to be done in regard to factors affecting recurrence and the duration of anticoagulation.