Response-guided neoadjuvant sacituzumab govitecan for localized triple-negative breast cancer: results from the NeoSTAR trial.

BACKGROUND: Sacituzumab govitecan (SG), a novel antibody-drug conjugate (ADC) targeting TROP2, is approved for pre-treated metastatic triple-negative breast cancer (mTNBC). We conducted an investigator-initiated clinical trial evaluating neoadjuvant (NA) SG (NCT04230109), and report primary results. PATIENTS AND METHODS: Participants with early-stage TNBC received NA SG for four cycles. The primary objective was to assess pathological complete response (pCR) rate in breast and lymph nodes (ypT0/isN0) to SG. Secondary objectives included overall response rate (ORR), safety, event-free survival (EFS), and predictive biomarkers. A response-guided approach was utilized, and subsequent systemic therapy decisions were at the discretion of the treating physician. RESULTS: From July 2020 to August 2021, 50 participants were enrolled (median age = 48.5 years; 13 clinical stage I disease, 26 stage II, 11 stage III). Forty-nine (98%) completed four cycles of SG. Overall, the pCR rate with SG alone was 30% [n = 15, 95% confidence interval (CI) 18% to 45%]. The ORR per RECIST V1.1 after SG alone was 64% (n = 32/50, 95% CI 77% to 98%). Higher Ki-67 and tumor-infiltrating lymphocytes (TILs) were predictive of pCR to SG (P = 0.007 for Ki-67 and 0.002 for TILs), while baseline TROP2 expression was not (P = 0.440). Common adverse events were nausea (82%), fatigue (76%), alopecia (76%), neutropenia (44%), and rash (48%). With a median follow-up time of 18.9 months (95% CI 16.3-21.9 months), the 2-year EFS for all participants was 95%. Among participants with a pCR with SG (n = 15), the 2-year EFS was 100%. CONCLUSIONS: In the first NA trial with an ADC in localized TNBC, SG demonstrated single-agent efficacy and feasibility of response-guided escalation/de-escalation. Further research on optimal duration of SG as well as NA combination strategies, including immunotherapy, are needed.

Endorsement of Feminist Beliefs, Openness, and Mindful Acceptance as Predictors of Decreased Transphobia.

The inclusion of transgender and gender nonconforming (TGNC) individuals in feminist theory, discourse, and activism is fraught with controversy. Given this historical tension within various feminism movements, the current study sought to understand the nature of the relationship between endorsement of feminist beliefs and transphobia, and whether the specific individual-level factors such as openness to experience and mindful acceptance, moderate such a relationship. Analyzing data from a sample of n = 211 participants recruited from the Amazon Mechanical Turk (MTurk) platform, the regression analyses indicate both endorsement of feminist beliefs and openness to experience are independent inverse predictors of transphobia, net of other variables in the regression models. However, openness to experience does not moderate the relationship between endorsement of feminist beliefs and transphobia. Further, mindful acceptance was not a significant predictor or moderating variable regarding transphobia. For the feminist community, this is an important contribution as it supports the idea that feminist attitudes may be inclusive of TGNC identities, along with the individual personality facet of openness to experience. Limitations and future directions are discussed.

Polyclonal RB1 mutations and acquired resistance to CDK 4/6 inhibitors in patients with metastatic breast cancer.

Background: While deregulation of the cyclin D1-CDK4/6-retinoblastoma pathway is common in hormone receptor positive (HR+) breast cancer, Rb is usually intact in HR+ breast cancer, and targeted CDK 4/6 inhibitors that act upstream of Rb, are routinely being utilized in clinical practice. However, factors that can lead to clinical resistance to CDK 4/6 inhibitors are not known. Patients and methods: We identified patients who had pre- and post-genotyping in tissue and peripheral blood samples after receiving CDK 4/6 inhibitors. Genotyping was carried out in tumor tissue or blood collected before start of CDK 4/6 inhibitor and after disease progression on CDK 4/6 inhibitor, covering more than 90% of the coding region in RB1. Results: We identified detectable acquired RB1 mutations in circulating tumor DNA (ctDNA) after exposure to CDK4/6 inhibitor (palbociclib, palbociclib, ribociclib) for 5, 8, and 13 months, respectively, in three patients. The RB1 mutations included substitution in donor splicing site of exon 8 of the RB1 gene in patient #1; substitution in donor splicing site of exon 22 of RB1 gene, exon 19 deletion, exon 3 insertion in patient #2; and RB1 exon 16 H483Y mutation in patient #3. None of these RB1 mutations were present in the pre-CDK 4/6 specimen highlighting these molecular alterations, which lead to functional loss of Rb1, likely emerged under selective pressure from the CDK4/6 inhibitor potentially confering therapeutic resistance. Conclusion: This is the first clinical report to describe the emergence of somatic RB1 mutations after exposure to palbociclib or ribociclib, in patients with metastatic breast cancer. Further research is needed to validate these findings, identify how these mutations temporally emerge under selective pressure of CDK 4/6 inhibitor, and develop rational therapeutic strategies.

'Am I really ready to go home?': a qualitative study of patients' experience of early discharge following an enhanced recovery programme for liver resection surgery.

PURPOSE: Fast-track surgery or enhanced recovery programmes (ERP) have been shown to improve patient outcomes with shorter post-operative recovery times, fewer complications and more cost-effective care amongst the reported benefits. Traditionally, the effectiveness of ERPs have been assessed by measuring clinical outcomes, with the patient experience often being neglected. The aim of this qualitative study was to ascertain patients' expectations and experiences of fast-track surgery and recovery at home within the setting of an enhanced recovery programme (ERP). METHOD: Twenty patients enrolled in the treatment group of the randomised controlled trial 'Enhanced recovery in liver resection surgery' were interviewed pre-operatively and 6 weeks post-surgery. Transcripts were analysed using thematic analysis. RESULTS: Patients approached the surgery with a sense of renewed hope. Involvement with the ERP was viewed positively, and having milestones to aim for gave patients a sense of purpose. Many felt that real recovery from surgery began at home and so felt positive about having an early discharge. Patients did report some concerns about being discharged early and those who failed to meet milestones or were readmitted to hospital experienced this as failure. CONCLUSIONS: This qualitative data demonstrates some of the complexities of patients' expectations and experiences of the ERP. Whilst patients generally experience the ERP positively, they also have concerns about the process. The study highlights areas where additional support may be needed for patients enrolled in ERPs and discharged early.

Control of magnetic ordering by Jahn--Teller distortions in Nd(2)GaMnO(6) and La(2)GaMnO(6).

The substitution of Ga(3+) into the Jahn--Teller distorted, antiferromagnetic perovskites LaMnO(3) and NdMnO(3) strongly affects both the crystal structures and resulting magnetic ordering. In both compounds the Ga(3+) and Mn(3+) cations are disordered over the six coordinate sites. La(2)GaMnO(6) is a ferromagnetic insulator (T(c) = 70 K); a moment per Mn cation of 2.08(5) mu(B) has been determined by neutron powder diffraction at 5 K. Bond length and displacement parameter data suggest Jahn--Teller distortions which are both coherent and incoherent with the Pnma space group symmetry of the perovskite structure (a = 5.51122(4) A, b = 7.80515(6) A, c = 5.52947(4) A) at room temperature. The coherent distortion is strongly suppressed in comparison with the parent LaMnO(3) phase, but the displacement ellipsoids suggest that incoherent distortions are significant and arise from local Jahn--Teller distortions. The preparation of the new phase Nd(2)GaMnO(6) has been found to depend on sample cooling rates, with detailed characterization necessary to ensure phase separation has been avoided. This compound also adopts the GdFeO(3)-type orthorhombically distorted perovskite structure (space group Pnma, a = 5.64876(1) A, b = 7.65212(2) A, c = 5.41943(1) A at room temperature). However, the B site substitution has a totally different effect on the Jahn--Teller distortion at the Mn(3+) centers. This phase exhibits a Q(2) mode Jahn--Teller distortion similar to that observed in LaMnO(3), although reduced in magnitude as a result of the introduction of Ga(3+) onto the B site. There is no evidence of a dynamic Jahn-Teller distortion. At 5 K a ferromagnetically ordered Nd(3+) moment of 1.06(6) mu(B) is aligned along the y-axis and a moment of 2.8(1) mu(B) per Mn(3+) is ordered in the xy plane making an angle of 29(2) degrees with the y-axis. The Mn(3+) moments couple ferromagnetically in the xz plane. However, along the y-axis the moments couple ferromagnetically while the x components are coupled antiferromagnetically. This results in a canted antiferromagnetic arrangement in which the dominant exchange is ferromagnetic. Nd(2)GaMnO(6) is paramagnetic above 40(5) K, with a paramagnetic moment and Weiss constant of 6.70(2) mu(B) and 45.9(4) K, respectively. An ordered moment of 6.08(3) mu(B) per Nd(2)GaMnO(6) formula unit was measured by magnetometry at 5 K in an applied magnetic field of 5 T.

Dihydropteroate synthase of Mycobacterium leprae and dapsone resistance.

Two Mycobacterium leprae genes, folP1 and folP2, encoding putative dihydropteroate synthases (DHPS), were studied for enzymatic activity and for the presence of mutations associated with dapsone resistance. Each gene was cloned and expressed in a folP knockout mutant of Escherichia coli (C600DeltafolP::Km(r)). Expression of M. leprae folP1 in C600DeltafolP::Km(r) conferred growth on a folate-deficient medium, and bacterial lysates exhibited DHPS activity. This recombinant displayed a 256-fold-greater sensitivity to dapsone (measured by the MIC) than wild-type E. coli C600, and 50-fold less dapsone was required to block (expressed as the 50% inhibitory concentration [IC(50)]) the DHPS activity of this recombinant. When the folP1 genes of several dapsone-resistant M. leprae clinical isolates were sequenced, two missense mutations were identified. One mutation occurred at codon 53, substituting an isoleucine for a threonine residue (T53I) in the DHPS-1, and a second mutation occurred in codon 55, substituting an arginine for a proline residue (P55R). Transformation of the C600DeltafolP::Km(r) knockout with plasmids carrying either the T53I or the P55R mutant allele did not substantially alter the DHPS activity compared to levels produced by recombinants containing wild-type M. leprae folP1. However, both mutations increased dapsone resistance, with P55R having the greatest affect on dapsone resistance by increasing the MIC 64-fold and the IC(50) 68-fold. These results prove that the folP1 of M. leprae encodes a functional DHPS and that mutations within this gene are associated with the development of dapsone resistance in clinical isolates of M. leprae. Transformants created with M. leprae folP2 did not confer growth on the C600DeltafolP::Km(r) knockout strain, and DNA sequences of folP2 from dapsone-susceptible and -resistant M. leprae strains were identical, indicating that this gene does not encode a functional DHPS and is not involved in dapsone resistance in M. leprae.

Contribution of rpoB mutations to development of rifamycin cross-resistance in Mycobacterium tuberculosis.

The contributions of 23 insertion, deletion, or missense mutations within an 81-bp fragment of rpoB, the gene encoding the beta-subunit of the DNA-dependent RNA polymerase of Mycobacterium tuberculosis, to the development of resistance to rifamycins (rifampin, rifabutin, rifapentine, and KRM-1648) in 29 rifampin-resistant clinical isolates were defined. Specific mutant rpoB alleles led to the development of cross-resistance to all rifamycins tested, while a subset of mutations were associated with resistance to rifampin and rifapentine but not to KRM-1648 or rifabutin. To further study the impact of specific rpoB mutant alleles on the development of rifamycin resistance, mutations were incorporated into the rpoB gene of M. tuberculosis H37Rv, contained on a mycobacterial shuttle plasmid, by in vitro mutagenesis. Recombinant M. tuberculosis clones containing plasmids with specific mutations in either codon 531 or 526 of rpoB exhibited high-level resistance to all rifamycins tested, whereas clones containing a plasmid with a mutation in codon 516 exhibited high-level resistance to rifampin and rifapentine but were susceptible to both rifabutin and KRM-1648. These results provided additional proof of the association of specific rpoB mutations with the development of rifamycin resistance and corroborate previous reports of the usefulness of rpoB genotyping for predicting rifamycin-resistant phenotypes.

Evaluation of a polymerase chain reaction-based universal heteroduplex generator assay for direct detection of rifampin susceptibility of Mycobacterium tuberculosis from sputum specimens.

In a double-blind study, 655 sputum specimens were obtained from individuals suspected of having tuberculosis and were analyzed for the presence of Mycobacterium tuberculosis and rifampin susceptibility with use of a polymerase chain reaction (PCR)-based universal heteroduplex generator assay (PCR/UHG-Rif). Of the specimens containing viable M. tuberculosis, 100% of the smear-positive (n = 41) and 50% of the smear-negative (n = 6) specimens tested positive for the organism by PCR/UHG-Rif. Nineteen of 537 culture-negative specimens tested positive for M. tuberculosis by PCR/UHG-Rif and were from patients with confirmed tuberculosis who were receiving antituberculosis therapy at the time of specimen collection. Thirty-five specimens contained nontuberculous mycobacteria and were negative by PCR/UHG-Rif. Genotypic evidence of rifampin resistance in five of six culture-confirmed, rifampin-resistant isolates was obtained by PCR/UHG-Rif, yielding a sensitivity and specificity for the assay of 83% and 98.2%, respectively. These results demonstrate the feasibility of using a PCR-based assay directly on sputum specimens for simultaneous detection of M. tuberculosis and rifampin susceptibility, and they suggest that patients with smear-positive, untreated tuberculosis and those presenting with suspected drug-resistant tuberculosis are the most appropriate groups for testing by PCR/UHG-Rif.