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Small cell lung cancer (SCLC) is the deadliest form of lung cancer and has few precision medicine approaches available. A recent study analyzed circulating tumor DNA (ctDNA) in 33 patients with extensive-stage SCLC and showed that ctDNA levels and response patterns correlate strongly with clinical response and survival outcomes. See related article by Sivapalan et al., p. xxxx

Opinion statementLimited-stage small cell lung cancer (LS-SCLC) is a potentially curable disease. However, most patients develop disease relapse shortly after definitive treatment. The landmark trials IMpower133 and CASPIAN demonstrated a survival benefit with the addition of immunotherapy to first-line platinum/etoposide for extensive-stage small cell lung cancer. Therefore, it is critical to determine whether advancements in overall survival with immunotherapy can be translated earlier into the treatment paradigm for LS-SCLC. Decades of robust preclinical research into the synergism of radiation therapy and immunotherapy set the stage for the combination of these treatment modalities. Recently published data suggests tolerability of single agent immunotherapy concurrent with chemoradiation in LS-SCLC, along with promising efficacy. However, combination immunotherapy in the consolidation setting appears too toxic, although this may be reflective of the dosing schedule rather than inherent to any combination immune checkpoint blockade. Here, we review underlying mechanisms of synergy with the combination of radiation and immunotherapy, the safety and efficacy of respective treatment modalities, and the ongoing trials that are exploring novel therapeutic approaches for LS-SCLC. Pivotal trials in LS-SCLC are ongoing and anticipated to aid in understanding efficacy and safety of immunotherapy with concurrent platinum-based chemoradiotherapy.

The optimal treatment for patients with oligometastatic non-small cell lung cancer (NSCLC) remains unclear. Some patients with oligometastatic disease can experience prolonged remission after locally consolidative radiation therapy (RT), while others harbor micrometastatic disease (below current limits of detection by imaging) that may benefit from further prioritization of systemic therapy. To better risk-stratify this population and identify the patients most likely to benefit from locally consolidative radiation therapy, we performed a multi-institutional cohort study of patients with oligometastatic NSCLC undergoing liquid biopsy analysis of circulating tumor DNA (ctDNA). Among this real-world cohort of 1,487 patients undergoing analysis (using the Tempus xF assay), a total of 1,880 ctDNA liquid biopsies along with paired clinical data were obtained across various timepoints. Approximately 20% (n=309) of patients had ctDNA obtained prior to RT and after their diagnosis of oligometastatic disease. Samples were de-identified and analyzed for mutational burden and variant frequencies of detectable deleterious (or likely deleterious) mutations in plasma. Patients with undetectable ctDNA before RT had significantly improved progression-free survival and overall survival compared to patients with detectable ctDNA prior to RT. In patients that received RT, 598 pathogenic (or likely deleterious) variants were identified. ctDNA mutational burden pre-RT and ctDNA maximum variant allele frequency (VAF) pre-RT were both significantly inversely correlated with both progression-free (P = 0.0031 for mutational burden, P = 0.0084 for maximum VAF) and overall survival (P = 0.045 for mutational burden, P = 0.0073 for maximum VAF). Patients without detectable ctDNA prior to RT had significantly improved progression-free survival (P = 0.004) and overall survival (P = 0.03) compared to patients with detectable ctDNA prior to RT. These data suggest that in patients with oligometastatic NSCLC, pre-radiotherapy ctDNA analysis can potentially identify the patients most likely to benefit from locally consolidative RT and experience prolonged progression-free and overall survival. Similarly, ctDNA may be useful to identify those patients with undiagnosed micrometastatic disease, in whom it may be appropriate to prioritize systemic therapy.

The detection of circulating tumor DNA via liquid biopsy has become an important diagnostic test for patients with cancer. While certain commercial liquid biopsy platforms designed to detect circulating tumor DNA have been approved to guide clinical decisions in advanced solid tumors, the clinical utility of these assays for detecting minimal residual disease after curative-intent treatment of nonmetastatic disease is currently limited. Predicting disease response and relapse has considerable potential for increasing the effective implementation of neoadjuvant and adjuvant therapies. As a result, many companies are rapidly investing in the development of liquid biopsy platforms to detect circulating tumor DNA in the minimal residual disease setting. In this review, we discuss the development and clinical implementation of commercial liquid biopsy platforms for circulating tumor DNA minimal residual disease detection of solid tumors. Here, we aim to highlight the technological features that enable highly sensitive detection of tumor-derived genomic alterations, the factors that differentiate these commercial platforms, and the ongoing trials that seek to increase clinical implementation of liquid biopsies using circulating tumor DNA-based minimal residual disease detection.

Background Activation of the mTOR pathway has been implicated in the development of several malignancies and alterations in TSC1, TSC2, STK11 and NF1, can lead to the dysregulation of this pathway. Furthermore, mutations in TSC1 and NF2 are known to confer sensitivity to everolimus-an mTOR inhibitor. Based on these data, a single-arm, open label, single-institution phase II basket study was designed to assess the activity of everolimus in patients with solid malignancies whose tumors harbored mutations in TSC1, TSC2, NF1, NF2, or STK11. Methods A total of 12 patients with histologically confirmed diagnosis of advanced solid tumors (metastatic, recurrent, or unresectable) with mutations in TSC1, TSC2, NF1, NF2 or STK11 genes, who had failed at least one line of standard of care systemic therapy, were enrolled to this open label, single-arm study. Presence of mutations in TSC1, TSC2, NF1, NF2 or STK11 genes was assessed using targeted-next generation sequencing (NGS). All eligible patients were treated with everolimus at an initial dose of 10 mg orally once daily in cycles of 28 days. The primary endpoint of this study was overall response rate (ORR). Results Of 12 patients enrolled, 8 were evaluable for response at the end of 2 cycles. One complete response (CR) was observed (12.5%) and one patient (12.5%) had stable disease (SD), while six (75%) patients showed disease progression. Everolimus was overall well tolerated with anemia, decreased neutrophil and lymphocyte counts, peripheral edema and hyperglycemia representing the most common adverse events. One patient discontinued treatment due to a treatment related grade 4 pericardial effusion. Both patients with CR or SD had a diagnosis of lung adenocarcinoma with NF1 or STK11 mutations, respectively. Conclusions Although this study failed to meet its prespecified ORR threshold for success of 30% or higher, exploratory analyses suggest potential activity for everolimus in a subset of patients with lung adenocarcinomas with STK11 or NF1 mutations. Further studies are necessary to systematically explore the clinical activity of everolimus, potentially as a combination therapy, in these patients.

Despite the presence of the KRASG12C oncogene, not all patients respond to KRASG12C inhibitors (e.g., sotorasib, adagrasib) and duration of response has been variable. We hypothesized that subtypes of KRASG12C lung cancers could be responsible for such differential effects. To define subtypes, we performed targeted exon sequencing, transcriptomics, proteomics, and phosphoproteomics on 46 frozen surgically resected KRASG12C lung adenocarcinomas. We employed unbiased consensus clustering methods, pathway analysis, and PTM-SEA to identify kinase signatures from phosphoproteomics data. Transcriptomics data revealed 4 clusters. Pathway enrichment showed that gene cluster (GC) 1 was enriched for immune pathways including interferon gamma response. Epithelial-mesenchymal transition (EMT), assessed by a TGF-β gene signature, was also enriched in GC1. 100% of GC1 overlapped the Proximal-Inflammatory subtype (Wilkerson et al.) and 53% with the mesenchymal subtype (Daemen et al.). GC2 was enriched for inflammatory response and TNF-alpha signaling. GC3 represented a metabolic phenotype with enriched xenobiotic metabolism and other metabolism pathways. 83% of GC3 overlapped with the Terminal Respiratory Unit subtype (Wilkerson et al.) and 56% with the proliferative subtype (Daemen et al.). GC4 only had 5 samples and did not have any significant enrichment. We next identified four proteomic clusters with distinct biology. Protein Cluster 1 (PC1) was enriched for immune pathways, PC2 was enriched for EMT, and PC3 was enriched for TNF/NF-κβ signaling. PC4 was enriched for xenobiotic and fatty acid metabolism and had significantly more KEAP1 mutations. We observed concordance of protein based clusters with mRNA based clusters, as PC1 largely overlapped with GC1 (70%) and PC4 largely overlapped with GC3 (86%). Cell type inference using xCell largely recapitulated the immune subtypes identified by transcriptomics and proteomics. GC1/PC1 had significantly more CD8+ effector memory T-cells, CD4+ Th2 T-cells, and M1 macrophages, while GC3/PC4 had significantly less of these same cell types. Collectively, GC1/PC1 represents 43% of the cohort and was defined by enrichment of immune pathways, elevated immune populations, and significantly higher PD-L1. Finally, we leveraged the phosphoproteomics data to determine whether signaling activity differs across subtypes. Using PTM-SEA, we identified phosphoproteomic signatures of activity for 50 kinases and pathways. We identified 26% of samples (N=12) with high EGFR activity, which is known to affect sensitivity of cells to KRASG12C inhibitors. The EGFR-high samples were observed across all genomic, transcriptomic, and proteomic subtypes. Our results suggest concordance of some transcriptomic and proteomic subtypes, including an immune subtype, while a metabolic protein subtype and EGFR high signaling subtype may provide additional subclasses with potential relevance for treatment responses. Additional phosphoproteomics signatures such as PLK1 and AKT1 may identify subtypes amenable to combination therapy approaches. Citation Format: Paul A. Stewart, Hitendra Solanki, Eric Welsh, Yaakov Stern, Denis Imbody, Yonghong Zhang, Bruna Pellini, Bin Fang, Sean Yoder, Steven Eschrich, Jamie Teer, John Koomen, Eric B. Haura. Proteogenomic landscape of KRASG12C lung adenocarcinomas reveals new subtypes and potential combination therapies [abstract]. In: Proceedings of the AACR Special Conference: Targeting RAS; 2023 Mar 5-8; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Res 2023;21(5_Suppl):Abstract nr A007.

More than 50 years after the discovery of RAS family proteins, which harbor the most common activating mutations in cancer, the U.S. Food and Drug Administration approved the first direct allele-specific inhibitor of mutant

Liquid biopsies for the diagnosis and treatment of lung cancer have developed rapidly, driven primarily by technical advances in sensitivity to detect circulating tumor DNA (ctDNA). Still, technical limitations such as the challenge of detecting low-level ctDNA variants and distinguishing tumor-related variants from clonal hematopoiesis remain. With further technical advancements, new applications for ctDNA analysis are emerging including detection of post-treatment molecular residual disease (MRD), clinical trial selection, and early cancer detection. This chapter reviews the current state of ctDNA testing in NSCLC, the underlying technological advances enabling ctDNA detection, and the potential to expand ctDNA analysis to new applications.

Circulating tumor DNA (ctDNA) minimal residual disease (MRD) is a powerful biomarker with the potential to improve survival outcomes for non–small-cell lung cancer (NSCLC). Multiple groups have shown the ability to detect MRD following curative-intent NSCLC treatment using next-generation sequencing–based assays of plasma cell-free DNA. These studies have been modest in size, largely retrospective, and without thorough prospective clinical validation. Still, when restricting measurement to the first post-treatment timepoint to assess the clinical performance of ctDNA MRD detection, they have demonstrated sensitivity for predicting disease relapse ranging between 36% and 100%, and specificity ranging between 71% and 100%. When considering all post-treatment follow-up timepoints (surveillance), including those beyond the initial post-treatment measurement, these assays' performances improve with sensitivity and specificity for identifying relapse ranging from 82% to 100% and 70% to 100%, respectively. In this manuscript, we review the evidence available to date regarding ctDNA MRD detection in patients with NSCLC undergoing curative-intent treatment and the ongoing prospective studies involving ctDNA MRD detection in this patient population.

The development of targeted therapies over the past two decades has led to a dramatic change in the management of EGFR-mutant non-small cell lung cancer (NSCLC). While there are currently five approved EGFR tyrosine kinase inhibitors (TKIs) for treating EGFR-mutant NSCLC in the first-line setting, therapy selection after progression on EGFR TKIs remains complex. Multiple groups are investigating novel therapies and drug combinations to determine the optimal therapy and treatment sequence for these patients. In this review, we summarize the landmark trials and history of the approval of EGFR TKIs, their efficacy and tolerability, and the role of these therapies in patients with central nervous system metastasis. We also briefly discuss the mechanisms of resistance to EGFR TKIs, ongoing attempts to overcome resistance and improve outcomes, and finalize by offering treatment sequencing recommendations.

Introduction: Circulating exosomes in blood have been considered as a treasure chest for biomarker discovery in cancer. Due to their heterogeneity, different isolation methods may enrich distinct exosome cargos generating different omic profiles. In this study, we evaluated the effects of plasma exosome isolation methods on detectable multiomic profiles in cancer patients and healthy controls. Methods: Plasma exosomes were isolated from prostate cancer patients (PC; N = 11), lung cancer patients (LC; N = 13), and matched healthy controls (HC; N = 10) using three methods [SBI (size exclusion), Takara (lectin binding), and Wako (Tim4 binding)]. Mass spectrometry was performed to determine exosome lipidome and metabolome profiles. To evaluate group-specific exosome enrichment, we developed an exosome enrichment index (EEI) by summing 50 smallest p-values after log2 transformation. Higher EEI indicates prefrential capture of significant exosome cargos from patients over controls. Results: Our data showed that the SBI method generated the most identified lipids from exosome across all groups (LC = 935, PC = 939, and HC = 943), followed by Takara (245, 245 and 245) and Wako (205, 208 and 213). Compared to controls, LC patients had 31 higher and 5 lower lipid levels (FDR < 0.1) using the SBI and 3 higher and 1 lower level (FDR < 0.1) using Takara. We did not observe any differences between cancer and normal samples using Wako. The most detectable known metabolites were found in exosomes from SBI (LC = 188, PC = 191, and HC = 100), followed by Wako (LC = 107, PC = 107, and HC = 107) and Takara (LC = 99, PC = 100, and HC = 100). Of the metabolites from SBI, 5 were significantly higher (FDR Conclusion: These results support that the SBI method can capture more heterogeneous exosome populations, possibly because this size exclusion-based method does not discriminate exosomes with different protein components. In contrast, Takara and Wako methods target exosome surface proteins, enriching specific exosome subpopulations resulting in less diversity of detectable lipids and metabolites. Overall, these findings suggest that exosome isolation methods can select subpopulations and determine the exosome content, which will significantly impact exosome-based biomarker discovery. Citation Format: Alex C. Soupir, Paul A. Stewart, Yury Nunez Lopez, Brandon J. Manley, Bruna Pellini, Jingsong Zhang, Qianxing Mo, Douglas C. Marchion, Min Lui, John M. Koomen, Erin M. Siegel, Liang Wang. Effects of plasma exosome isolation methods on detectable multiomic profiles in cancer patients and healthy controls [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3417.

The treatment paradigm for patients with advanced non–small cell lung cancer has substantially changed with the discovery of immunotherapy. The incorporation of immunotherapy into treatment algorithms has resulted in better outcomes for patients, with fewer side effects compared with classic chemotherapeutic agents. Multiple treatment options are now available for patients with advanced non–small cell lung cancer, ranging from single-agent immunotherapy to quadruple therapy, which involves dual immune checkpoint inhibitor plus chemotherapy or immune checkpoint inhibitor plus chemotherapy plus anti–vascular endothelial growth factor drugs. This article will review landmark studies that have led to U.S. Food and Drug Administration approval of immunotherapy agents alone or in combination with chemotherapy or other immunotherapy drugs to treat advanced non–small cell lung cancer.

BACKGROUND: Activation of the mTOR pathway has been implicated in the development of several malignancies and alterations in TSC1, TSC2, STK11 and NF1, can lead to the dysregulation of this pathway. Furthermore, mutations in TSC1 and NF2 are known to confer sensitivity to everolimus—an mTOR inhibitor. Based on these data, a single-arm, open label, single-institution phase II basket study was designed to assess the activity of everolimus in patients with solid malignancies whose tumors harbored mutations in TSC1, TSC2, NF1, NF2, or STK11. METHODS: A total of 12 patients with histologically confirmed diagnosis of advanced solid tumors (metastatic, recurrent, or unresectable) with mutations in TSC1, TSC2, NF1, NF2 or STK11 genes, who had failed at least one line of standard of care systemic therapy, were enrolled to this open label, single-arm study. Presence of mutations in TSC1, TSC2, NF1, NF2 or STK11 genes was assessed using targeted-next generation sequencing (NGS). All eligible patients were treated with everolimus at an initial dose of 10 mg orally once daily in cycles of 28 days. The primary endpoint of this study was overall response rate (ORR). RESULTS: Of 12 patients enrolled, 8 were evaluable for response at the end of 2 cycles. One complete response (CR) was observed (12.5%) and one patient (12.5%) had stable disease (SD), while six (75%) patients showed disease progression. Everolimus was overall well tolerated with anemia, decreased neutrophil and lymphocyte counts, peripheral edema and hyperglycemia representing the most common adverse events. One patient discontinued treatment due to a treatment related grade 4 pericardial effusion. Both patients with CR or SD had a diagnosis of lung adenocarcinoma with NF1 or STK11 mutations, respectively. CONCLUSIONS: Although this study failed to meet its prespecified ORR threshold for success of 30% or higher, exploratory analyses suggest potential activity for everolimus in a subset of patients with lung adenocarcinomas with STK11 or NF1 mutations. Further studies are necessary to systematically explore the clinical activity of everolimus, potentially as a combination therapy, in these patients.

PURPOSE We hypothesized that circulating tumor DNA (ctDNA) molecular residual disease (MRD) analysis without prior mutational knowledge could be performed after neoadjuvant chemotherapy to assess oligometastatic colorectal cancer (CRC) treated surgically with curative intent. We also investigated urine as an alternative analyte for ctDNA MRD detection in this nongenitourinary setting. PATIENTS AND METHODS We applied AVENIO targeted next-generation sequencing to plasma, tumor, and urine samples acquired on the day of curative-intent surgery from 24 prospectively enrolled patients with oligometastatic CRC. Age-related clonal hematopoiesis was accounted for by removing variants also present in white blood cells. Plasma and urine ctDNA MRD were correlated with tumor cells detected in the surgical specimen, and adjuvant treatment strategies were proposed based on ctDNA-inferred tumor mutational burden (iTMB) and targetable alterations. RESULTS Seventy-one percent of patients were treated with neoadjuvant chemotherapy. Tumor-naive plasma ctDNA analysis detected MRD at a median level of 0.62% with 95% sensitivity and 100% specificity, and 94% and 77% sensitivity when only considering patients treated with neoadjuvant chemotherapy and putative driver mutations, respectively. In urine, ctDNA MRD detection specificity remained high at 100%, but sensitivity decreased to 64% with median levels being 11-fold lower than in plasma ( P < .0001). Personalized ctDNA MRD oncogenomic analysis revealed 81% of patients might have been candidates for adjuvant immunotherapy based on high iTMB or targeted therapy based on actionable PIK3CA mutations. CONCLUSION Tumor-naive plasma ctDNA analysis can sensitively and specifically detect MRD in patients with oligometastatic CRC after neoadjuvant chemotherapy. Urine-based ctDNA MRD detection is also feasible; however, it is less sensitive than plasma because of significantly lower levels. Oligometastatic patients with detectable MRD may benefit from additional personalized treatment based on ctDNA-derived oncogenomic profiling.

Simple Summary The detection of DNA methylation changes in blood has emerged as a promising approach for cancer diagnosis and management. Our group has previously optimized a blood DNA methylation profiling technology that is based on affinity capture of methylated DNA, termed cfMBD-seq. The aim of this study was to assess the potential clinical feasibility of cfMBD-seq. We applied cfMBD-seq to the blood samples of cancer patients and identified methylation signatures that can not only discriminate cancer patients from cancer-free individuals but can also enable accurate multi-cancer classification. Our findings will help to expand on existing blood-based molecular diagnostic tests and identify novel methylation biomarkers for early cancer detection and classification. Abstract Cell-free DNA (cfDNA) methylation has emerged as a promising biomarker for early cancer detection, tumor type classification, and treatment response monitoring. Enrichment-based cfDNA methylation profiling methods such as cfMeDIP-seq have shown high accuracy in the classification of multiple cancer types. We have previously optimized another enrichment-based approach for ultra-low input cfDNA methylome profiling, termed cfMBD-seq. We reported that cfMBD-seq outperforms cfMeDIP-seq in the enrichment of high-CpG-density regions, such as CpG islands. However, the clinical feasibility of cfMBD-seq is unknown. In this study, we applied cfMBD-seq to profiling the cfDNA methylome using plasma samples from cancer patients and non-cancer controls. We identified 1759, 1783, and 1548 differentially hypermethylated CpG islands (DMCGIs) in lung, colorectal, and pancreatic cancer patients, respectively. Interestingly, the vast majority of DMCGIs were overlapped with aberrant methylation changes in corresponding tumor tissues, indicating that DMCGIs detected by cfMBD-seq were mainly driven by tumor-specific DNA methylation patterns. From the overlapping DMCGIs, we carried out machine learning analyses and identified a set of discriminating methylation signatures that had robust performance in cancer detection and classification. Overall, our study demonstrates that cfMBD-seq is a powerful tool for sensitive detection of tumor-derived epigenomic signals in cfDNA.

BACKGROUND: Circulating tumor DNA (ctDNA) can detect molecular residual disease (MRD) in plasma after curative-intent treatment of non-metastatic solid tumor malignancy when prior mutational knowledge from either tumor or pre-treatment plasma is available. We hypothesized that ctDNA MRD analysis without prior mutational knowledge could be performed to assess oligometastatic colorectal cancer (CRC) treated with curative intent by applying an error-corrected ultra-deep targeted sequencing approach. We also investigated urine as an alternative analyte for ctDNA MRD detection in this non-genitourinary setting. METHODS: We applied AVENIO, a ctDNA technology derived from CAncer Personalized Profiling by deep Sequencing (CAPP-Seq) with integrated digital error suppression (iDES), to plasma, tumor, and urine samples acquired on the day of surgery from 24 prospectively enrolled oligometastatic CRC patients. We sequenced patients' white blood cell DNA to remove age-related clonal hematopoiesis variants. Plasma and urine ctDNA MRD detection were then correlated with residual disease present in tumor tissue, and adjuvant treatment strategies were proposed based on plasma ctDNA-inferred tumor mutational burden and targetable genomic alterations. RESULTS: Tumor-naïve plasma ctDNA analysis detected MRD at a median level of 0.62% with 95% sensitivity and 100% specificity. Plasma ctDNA MRD levels correlated with tumor size at the time of surgery (ρ= 0.68, P = 0.0003) and were significantly lower in patients without evidence of disease in their surgical specimen compared to those with residual tumor cells (P = 0.02). In urine, ctDNA MRD detection specificity remained high at 100%, but sensitivity was lower at 64%, with median levels being 11-fold lower than in plasma (P < 0.0001). Cell-free DNA fragments containing mutations were shorter in urine with an average size of 150.1 bp, compared to 180.2 bp in plasma (P < 0.0001). Personalized ctDNA MRD oncogenomic analysis revealed that 81% of patients had a high inferred tumor mutational burden (>10 mutations/megabase), and 10% also had a targetable PIK3CA mutation. CONCLUSION: Tumor-naïve plasma ctDNA analysis can sensitively and specifically detect MRD in patients with oligometastatic CRC after neoadjuvant chemotherapy. Urine-based ctDNA MRD detection is also feasible in these patients; however, it is less sensitive than plasma. Analysis of oligometastatic CRC patients' ctDNA MRD also revealed potentially actionable results that might have implications for personalized adjuvant treatment regimens. Citation Format: Bruna Pellini, Nadja Pejovic, Wenjia Feng, Noah Earland, Peter K. Harris, Abul Usmani, Jeffrey J. Szymanski, Farid Qaium, Jacqueline Mudd, Hyun Kim, Benjamin Tan, Ryan C. Fields, Aadel A. Chaudhuri. ctDNA MRD detection from plasma and urine and personalized oncogenomic analysis in oligometastatic colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 543.

Objectives Identify predictors of outcome in patients with recurrent/metastatic head and neck squamous cell carcinoma (RMHNSCC) treated with weekly cetuximab and paclitaxel (CP). Study Design Retrospective analysis. Methods Patients with RMHNSCC treated with CP were identified and patient data was recorded. The Kaplan-Meier method was used to estimate outcomes, and Cox regression analysis was used to examine outcome predictors. Results Fifty-nine patients initiated CP between January 2007 and June 2014. Median age was 56 (range: 39–80) years. The most common primary sites were the oropharynx in 22 (37%) patients, oral cavity in 19 (32%), and larynx in 11 (19%). Eastern Cooperative Oncology Group performance status (ECOG PS) was 0 in seven (12%), 1 in 32 (54%), and 2 in 16 (28%) patients. In 44 (75%) patients, CP was used as a first-line R/M regimen. Median number of cycles was five (range: 1–29). Dose modifications were necessary in 27 (46%) patients. The objective response rate was 47.5%, with 27 (45.8%) partial responses and one (2%) complete response. With a median follow-up of 13.4 months, median progression-free (PFS) and overall survival (OS) were 7.7 and 13.2 months, respectively. On multivariable analysis, an ECOG of 2 of 3 was associated with inferior OS (hazard ratio [HR]: 3.94; P = 0.01; 95% confidence interval [CI]: 1.1–14.04) and PFS (HR: 7.29; P < 0.01; 95% CI: 2.1–26.0) compared to an ECOG 0 of 1. First-line CP administration was associated with superior PFS compared to second line (HR: 2.6; P = 0.02; 95% CI:1.2–5.5). Conclusions CP is well tolerated in this population of patients, with favorable tumor efficacy. First-line use and an ECOG 0 of 1 points appears to confer superior outcomes. Level of Evidence 4. Laryngoscope, 127:1583–1588, 2017

Development of graft-versus-host disease (GvHD) is a rare complication after transfusions or solid organ transplantation. Patients typically present with a skin rash, diarrhea, liver failure, and bone marrow aplasia. A diagnosis of transfusion/transplantation associated-GvHD is made based on the clinical and histologic evidence, yet it is often delayed due to the nonspecific symptoms attributed to the patient's underlying illness. Several therapeutic approaches are being used including both increasing and withdrawing immunosuppression, and the use of cellular therapies. Unfortunately, the success rate of these approaches is low and the mortality of this complication is very high. New approaches are needed. We report on three cases of GvHD developing after solid organ transplantation treated with ruxolitinib.

e15545 Background: Cell-free DNA (cfDNA) analysis from blood is a useful liquid biopsy strategy. However, it requires phlebotomy and moderate volumes of plasma. Here, we explored the feasibility of urinary cfDNA (ucfDNA) analysis in patients with oligometastatic colorectal cancer (CRC). Methods: We applied error-corrected targeted next-generation sequencing (NGS) (AVENIO ctDNA surveillance assay) to 10 patients with oligometastatic CRC to the liver who underwent curative-intent surgery. 40 paired samples (tumor, plasma, urine supernatant, peripheral blood mononuclear cells (PBMCs)) were collected, from which DNA was extracted. Plasma and urine cfDNA samples (acquired preoperatively) were sequenced to a median de-duplicated depth of 8,065X with on-target rate of 71%. Similarly high depth targeted NGS was applied to tumor and PBMC samples. Variants were called from plasma cfDNA and tumoral DNA and queried in ucfDNA using methods derived from CAncer Personalized Profiling by deep Sequencing (CAPP-Seq) with integrated digital error suppression (iDES). Clonal hematopoiesis was accounted for by removing mutations also present in PBMCs. Results: Patients had a median of 2 tumors resected (range 1-7) with average sum of longest diameters of 8.7 cm (range 0.6-11). We used an average of 10 ml of blood and 37 ml of urine for cfDNA extraction. Circulating tumor DNA (ctDNA) was detected in all preoperative plasma samples (n = 10) at a mean mutant allele fraction (MAF) of 2.35% (range 0.09-11.78). Plasma ctDNA MAFs correlated significantly with tumor SLD (Pearson r = 0.81, P = 0.03). The average number of single nucleotide variants detected in plasma cfDNA, tumor and ucfDNA was 8 (range 1-42), 4 (range 1-7) and 2 (range 0-11), respectively. Indicative of concordance, 79% of the mutations called in tumor were detected in plasma. Tumor-derived DNA was detected in the preoperative urine of 6 patients (60%) with a MAF of 0.05% (range 0.03-0.12), ~35-fold less than in plasma (MAF of 1.78%, range 0.09-7.94) (P = 0.004). 38% of mutations identified in tumor and 26% from plasma were detected in ucfDNA for these 6 patients. In two patients, targetable mutations (BRAF p.Asp594Gly and PIK3CA p.Glu545Lys) present in tumor were also detected in ucfDNA, with the latter not detected in plasma. Conclusions: Our results indicate that ucfDNA analysis in patients with oligometastatic CRC is feasible; however, the mutational levels and detection sensitivity were much lower than from plasma. Yet, there may be situations where actionable mutations are missed in plasma but detected in urine.

Purpose Breast cancer is a heterogeneous disease. Immunohistochemistry has given rise to triple-negative carcinoma (TNC). Concomitantly, biological origins of neoplasia and its heterogeneity has been strongly debated in cancer stem cells (CSC) theme. This study investigates the prevalence of basal (BCC) and penta-negative carcinomas (5NC) in TNC and establishes associations with CSC (CD44CD24). Materials and methods 94 TNC were tested for CK5/6, HER1, CD44 and CD24, evaluated by a simple immunohistochemistry score and correlated with clinicopathological and survival data. Results BCC had higher tumor grades than 5NC ( p = 0.004). CD44 negativity ( p = 0.007) and CD44 − CD24 + phenotype ( p = 0.013) were associated with less vascular invasion amongst TNC. CD44 expression was associated with BCC ( p = 0.007). CD44 − CD24 −/low phenotype was associated with 5NC. None of the variables were associated with clinical outcome. Conclusion BCC and 5NC are closely related tumor subtypes. CD44 − CD24 −/low phenotype was associated with 5NC and CD44 − CD24 + phenotype was associated with vascular invasion. These results require histogenetic confirmation in larger studies.

Identify predictors of outcome in patients with recurrent/metastatic head and neck squamous cell carcinoma (RMHNSCC) treated with weekly cetuximab and paclitaxel (CP).Retrospective analysis.Patients with RMHNSCC treated with CP were identified and patient data was recorded. The Kaplan-Meier method was used to estimate outcomes, and Cox regression analysis was used to examine outcome predictors.Fifty-nine patients initiated CP between January 2007 and June 2014. Median age was 56 (range: 39-80) years. The most common primary sites were the oropharynx in 22 (37%) patients, oral cavity in 19 (32%), and larynx in 11 (19%). Eastern Cooperative Oncology Group performance status (ECOG PS) was 0 in seven (12%), 1 in 32 (54%), and 2 in 16 (28%) patients. In 44 (75%) patients, CP was used as a first-line R/M regimen. Median number of cycles was five (range: 1-29). Dose modifications were necessary in 27 (46%) patients. The objective response rate was 47.5%, with 27 (45.8%) partial responses and one (2%) complete response. With a median follow-up of 13.4 months, median progression-free (PFS) and overall survival (OS) were 7.7 and 13.2 months, respectively. On multivariable analysis, an ECOG of 2 of 3 was associated with inferior OS (hazard ratio [HR]: 3.94; P = 0.01; 95% confidence interval [CI]: 1.1-14.04) and PFS (HR: 7.29; P0.01; 95% CI: 2.1-26.0) compared to an ECOG 0 of 1. First-line CP administration was associated with superior PFS compared to second line (HR: 2.6; P = 0.02; 95% CI:1.2-5.5).CP is well tolerated in this population of patients, with favorable tumor efficacy. First-line use and an ECOG 0 of 1 points appears to confer superior outcomes.4. Laryngoscope, 127:1583-1588, 2017.

The ability to understand the features of the white blood cell is an important skill for medical undergraduates. The objective was to develop a game that would improve medical students' knowledge about the value and interpretation of the white blood cell. The game consists of 63 cards, including different clinical cases involving conditions that modify white blood cell count, related laboratory findings, and the respective diagnosis. The objective of the game was to match the three groups of cards, explaining their association. The evaluation tools included pretests and posttests, in addition to a structured questionnaire to identify the overall perception of the game. The game was applied to 90 undergraduate pre-clinical medical students of the Universidade Federal do Rio Grande do Sul, Brazil. The results of this study show that pretest and posttest mean scores were 8.6 ( ± 1.62) and 9.27 ( ± 1.30), with a statistically significant difference. Thirty-seven students (39.4%) did not know the answer to at ...

Dermatofibrosarcoma protuberans (DFSP) and inflammatory myofibroblastic tumor (IMT) are rare malignancies with the capacity to be locally invasive but with low metastatic potential. DFSP is characterized by the translocation t(17;22)(q22;q13), resulting in the COL1A1–PDGFβ fusion protein. Imatinib mesylate has shown activity in the treatment of unresectable or metastatic DFSP, achieving an RECIST response rate close to 50% in phase II trials. These results have established imatinib as standard systemic therapy for patients with unresectable or metastatic DFSP.

Primary splenic angiosarcoma is a very rare neoplasm with a high propensity for metastatic disease and poor prognosis. There is a paucity of literature concerning this specific sarcoma subtype and the role of systemic therapy is not well defined. A retrospective review of the prospectively maintained University of Washington/Seattle Cancer Care Alliance Sarcoma Unit database was performed to identify patients with splenic angiosarcoma treated between 2007 and 2012. In total there were 19 patients with angiosarcoma treated at the Seattle Cancer Care Alliance from 2007 to 2012. The number of patients with splenic angiosarcoma was 2 (11%). The first patient was a woman aged 57 years who was referred with metastatic splenic angiosarcoma to the liver, post-splenectomy. She was treated with 4 cycles of weekly paclitaxel prior to metastatic resection and 4 cycles of the same drug in an adjuvant scenario, achieving a pathological complete response to treatment. She is alive and on third-line systemic therapy. The second patient was a male patient aged 30 years who presented with metastatic high-grade splenic angiosarcoma and was treated with 3 lines of systemic therapy, including doxorubicin, paclitaxel and gemcitabine+docetaxel, but developed a gastrointestinal metastasis with subsequent gastrointestinal bleeding. Splenic angiosarcoma is a very rare neoplasm. Surgery remains the mainstay of management for localized disease. Paclitaxel administered weekly proved to be well-tolerated and resulted in a good radiological response in one of our patients, enabling resection of metastatic disease. Durable clinical benefit can be achieved in metastatic splenic angiosarcoma with multi modality management.

e17065 Background: Patients (pts) with RMHNSCC commonly present with a poor PS that makes them inelegible to receive cisplatin based chemotherapy. Our group has adopted the CP regimen for RMHNSCC. ...