Joseph, Richard W.

Hidradenocarcinoma is a rare aggressive form of cutaneous adnexal skin carcinoma originating from the sweat gland. Due to its low incidence, prognostic and treatment strategies are still being explored both for primary and advanced disease. This tumor most often presents as either solid or cystic appearing subcutaneous nodules, which may be associated with pruritus or ulceration. To date the mainstay of treatment for local disease has been surgical excision; however, the paucity of historical data available has shown that these tumors often behave aggressively with high rates of local recurrence, metastasis, and poor overall outcomes. There are few case reports describing the utility of radiation therapy in the treatment of hidradenocarcinoma. Herein, we present a case of metastatic apocrine hidradenocarcinoma in a 32-year-old Caucasian male. The patient initially underwent excisional biopsy which confirmed the diagnosis of poorly differentiated, highly infiltrative, apocrine hidradenocarcinoma. He received systemic chemotherapy for metastatic disease, followed by radiation therapy to areas of grossly palpable adenopathy. Prior to radiation therapy the patient had an enlarged hypermetabolic conglomerate of lymph nodes in the right axilla, and borderline enlarged low activity nodes within the left axilla. He received 3 cycles of chemotherapy followed by tamoxifen and radiation therapy (50.4 Gy in 28 fractions) to areas of progressive disease in the bilateral axilla, lower neck, and axillary skin. Following treatment, the patient had complete resolution of skin nodules and improvement of his pruritus. While the role of radiation therapy in the treatment of hidradenocarcinoma has not been well established, this case report demonstrated the potential benefit of external beam radiotherapy in the management of this rare disease.

Abstract Monoclonal antibodies that target the programmed death-1 (PD-1)–programmed death ligand-1 (PD-L1) axis have antitumor activity against multiple cancers. The presence of sarcomatoid differentiation in renal cell carcinoma (RCC) is associated with resistance to targeted therapy and poor responses to IL2 immunotherapy. Given the aggressive nature of RCC with sarcomatoid differentiation and the exclusion of sarcomatoid histology from metastatic RCC clinical trials, less is understood regarding selection of therapies. Here, we characterized the PD-1/PD-L1 axis in RCC with sarcomatoid differentiation. We directly compared two PD-L1 antibodies and found concordance of PD-L1 positivity in 89% of tested RCCs with sarcomatoid differentiation. Coexpression of PD-L1 on neoplastic cells and the presence of PD-1–positive tumor-infiltrating lymphocytes were identified in 50% (13 of 26) of RCCs with sarcomatoid differentiation. In contrast, only 1 of 29 clear cell RCCs (3%) had concurrent expression of PD-L1 and PD-1 (P = 0.002). Our study suggests that RCC with sarcomatoid differentiation may express PD-1/PD-L1 at a higher percentage than RCC without sarcomatoid differentiation, and patients with these tumors may be good candidates for treatment with anti–PD-1/PD-L1 therapies. Cancer Immunol Res; 3(12); 1303–7. ©2015 AACR.

Abstract Targeted therapies and immunotherapies have led to significant improvements in the treatment of advanced cancers, including metastatic melanoma. However, new strategies are desperately needed to overcome therapeutic resistance to these agents, as well as to identify effective treatment approaches for cancer patients that fall outside major targetable mutational subtypes (e.g., non–V600 BRAF melanoma). One such strategy is to extend the paradigm of individually tailored, molecularly targeted therapy into a broader spectrum of melanoma patients, particularly those bearing tumors without commonly recognized therapeutic targets, as well as having failed or were ineligible for immunotherapy. In this nontreatment pilot study, next-generation sequencing (NGS) technologies were utilized, including whole genome and whole transcriptome sequencing, to identify molecular aberrations in patients with non–V600 BRAF metastatic melanoma. This information was then rationally matched to an appropriate clinical treatment from a defined pharmacopeia. Five patients with advanced non–V600 BRAF metastatic melanoma were enrolled. We demonstrated successful performance of the following during a clinically relevant time period: patient tumor biopsy, quality DNA/RNA extraction, DNA/RNA-based sequencing for gene expression analysis, analysis utilizing a series of data integration methodologies, report generation, and tumor board review with formulated treatment plan. Streamlining measures were conducted based on the experiences of enrolling, collecting specimens, and analyzing the molecular signatures of patients. We demonstrated the feasibility of using NGS to identify molecular aberrations and generate an individualized treatment plan in this patient population. A randomized treatment study utilizing lessons learned from the conduct of this pilot study is currently underway. Mol Cancer Ther; 14(8); 1962–71. ©2015 AACR.

Abstract Background: Extranodal follicular dendritic cell sarcoma (FDCS) is an exceedingly rare tumor type that is limited to few cases in the literature. Given the rarity of this tumor, there is a lack of genetic understanding of this disease resulting in a non-individualized plan of care for patients with this disease. Herein, we are the first to describe extensively molecularly the DNA and RNA of this tumor. Methods: Under an IRB approved protocol, the patient's tumor and whole blood was freshly frozen for molecular analysis. We performed Next Generation Sequencing (NGS) genomic profiling including exome capture, mate pair and mRNA sequencing on this tumor. Exome and mRNA data were processed through Mayo's Bioinformatics Core standard pipelines, GENOME GPS 1.2.1 and MAPRSeq v1.2.1. Mutations and indels were prioritized depending on whether or not they belonged to known cancer associated genes. Copy number variations (CNVs) in Exome and Mate Pair data was found through PatternCNV v 1.0.1 and fusion transcripts were found using SNOWSHOES-FTD and Tophat-Fusion 2.0.6. Results: At the genomic level large scale genomic rearrangements were detected, including chr19 and chr20 trisomy, chr15q and chr17q segmental duplications result in two intra-chromosomal fusion genes, and translocations leading to four inter-chromosomal fusion genes between chr15 and chr17. Of particular interest is a stop codon gain in the CLTC1 (chr22) gene, which is involved in the mitotic spindle organization which has been associated with meningiomas and breast tumorigenesis. The new stop codon is before the site required for the recruitment of the proteins to the spindle. The large scale genomic rearrangement described above is consistent with this defective spindle assembly hypothesis. Another intriguing mutation detected in the VEGFR1 (chr13) gene leads to a 45% mis-spliced transcript. VEGFR1 is thought to modulate VEGFR2 which plays an essential role in angiogenesis, by acting as a decoy receptor. Therefore the loss of function of VEGFR1 might lead to hyper-activity of VEGFR2 pathway and a potential therapeutic strategy is to directly inhibit the VEGFR2 pathway. Furthermore missense mutations in the ATM (chr11) and TP53 (chr17) genes were found. PARP inhibitors have been used with success for cancer with defects in the ATM gene. Finally a novel fusion transcript of HDGRFP3 (chr15) and SHC4 (chr15) was identified. Such fusion results in an overexpressed SHC4 gene which has been associated with metastatic melanomas. Conclusions: In summary, genomic profiling of a rare thyroid FDCS identified drug targetable genes as well as changes related to tumor etiology. Future work is necessary to determine the functional significance of these molecular findings and whether they will predict benefit to targeted therapies. Citation Format: Jaime I. Davila, Jason Starr, Steven Attia, Chen Wang, Xue Wang, Brian Necela, Casler John, David Menke, Vivek Sarangi, Gavin Oliver, Richard Joseph, John Copland, Alexander Parker, E. Aubrey Thompson, Robert Smallridge, Yan W. Asmann. Extensive genomic profiling of a rare extranodal-follicular dendritic cell sarcoma: Implications for future individualized therapy. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1894. doi:10.1158/1538-7445.AM2014-1894

Abstract Background: Previous data on the relationship between PD-L1 expression and activity of anti-PD-1 and anti-PD-L1 antibodies have been conflicting. MK-3475, a humanized monoclonal IgG4 antibody against PD-1, has demonstrated durable antitumor activity in MEL and NSCLC. We evaluated tumor PD-L1 expression and its relationship with outcomes in a phase I clinical trial of MK-3475. We also evaluated T cell activation as a pharmacodynamic marker of MK-3475 activity. Methods: 135 MEL pts received MK-3475 10 mg/kg Q2W, 10 mg/kg Q3W, or 2 mg/kg Q3W. Tumor response was assessed by RECIST 1.1 per independent central review, including requirement for a confirmatory CT scan. Pretreatment biopsy was required. Serial blood samples were collected before infusion at the start of cycles 1-5 (Q2W dosing) or 1-4 (Q3W dosing). Tumor PD-L1 expression was assessed by IHC. A preliminary cutoff of 1% of stained cells was used to define PD-L1 positivity. Absolute CD4+ and CD8+ T cell counts and the percentage of activated (HLA-DR as marker) CD4+ and CD8+ T cells in peripheral blood were assessed by multiplex flow cytometry (n = 101). Results: Median PFS was 36 weeks, 6-month overall survival (OS) rate was 89%, and 12-month OS rate was 81%. Median duration of response and OS were not reached. In the 116 pts with measurable disease, ORR was 41%. PFS and response rate were significantly associated with tumor PD-L1 expression (Table). At week 6, a statistically significant percent increase from baseline in the percentage of activated (HLA-DR+) CD4+ and CD8+ T cells was observed at all doses (pooled mean percent change [SE], +24.0% [4.7%] for HLA-DR+/CD8+, +17.5% [2.7%] for HLA-DR+/CD4+). Conclusions: Tumor PD-L1 expression levels were associated with tumor response and PFS in MEL pts treated with MK-3475; activity was also observed in pts with low PD-L1 expression. As assessed by HLA-DR expression, post-treatment T cell activation in the circulating pool was increased at all doses tested. Patients WithMeasurable Disease and Interpretable PD-L1 IHC ResultsPatients With InterpretablePD-L1 IHC Results and PFS and OS Data PD-L1 TumorExpressionNORR, n (%)NPFS at 6 months, % (95% CI)Median PFSOS at 6 months, % (95% CI)Median OSPositive (membrane staining in ≥1% of cells)5529 (53)6058 (47-72)10.6 mo93(87-100)Not reachedNegative (membrane staining in <1% of cells)161* (6)2232 (16-64)2.9 mo75(58-97)Not reachedHR (95% CI) for PD-L1-positive vs negative____0.54(0.28-1.05)_0.67(0.25-1.83)One-sidedP value(PD-L1 association test)_<0.004 (logistic regression)__0.034(Cox regression)_0.220(Cox regression)*IPI-pretreated patient who received MK-3475 10 mg/kg Q2W. Citation Format: Adil I. Daud, Omid Hamid, Antoni Ribas, F. Stephen Hodi, Wen-Jen Hwu, Richard Kefford, Jedd Wolchok, Peter Hersey, Jeffrey S. Weber, Richard Joseph, Tara C. Gangadhar, Roxana S. Dronca, Amita Patnaik, Hassane Zarour, Anthony M. Joshua, Kevin Gergich, Dianna Wu, Jared K. Lunceford, Kenneth Emancipator, Marisa Dolled-Filhart, Nicole Li, Scot Ebbinghaus, S. Peter Kang, Caroline Robert. Antitumor activity of the anti-PD-1 monoclonal antibody MK-3475 in melanoma(MEL): Correlation of tumor PD-L1 expression with outcome. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr CT104. doi:10.1158/1538-7445.AM2014-CT104

Abstract Background: Renal cell carcinoma (RCC) is the most common type of kidney cancer responsible for ∼80% of kidney cancer cases. Circulating tumor cells (CTCs) are emerging as an important prognostic and predictive biomarker in several types of metastatic cancers. However, methods for CTC detection that target only EpCAM and/or cytokeratin (CK) to enrich CTCs, may fail to recognize the CTCs in clear cell RCC (ccRCC) because ccRCC lacks expression of EpCAM. The objective of this study was to develop a new technology capable of detecting CTCs including those with a mesenchymal phenotype in metastatic RCC. Methods: Blood samples from patients affected by metastatic RCC were provided by Mayo Clinic Arizona and analyzed by Creatv MicroTech. CellSieveTM microfilters, which have 7 µm diameter pores in a uniform array, with 160,000 pores in a 9 mm diameter area, were used for separation of CTCs in the blood specimen. 7.5 mL of whole blood was diluted in the prefixation buffer and filtered through the microfilter. Clinical immunohistochemical markers for RCC such as CD10 and vimentin were used to identify candidate CTCs. The cells collected on the filter were fixed, permeabilized, and stained with DAPI and fluorescent antibodies specific to CD10, vimentin, and CD45. The assay protocol was developed using three RCC cell lines, 786-O, Caki-1, and Caki-2, and validated using blood samples from patients with metastatic RCC. Results: The capture efficiencies for 786-O, Caki-1, and Caki-2 cell lines were determined to be 98%, 98% and 97%, respectively. On-filter antibody staining revealed heterogeneous expressions of vimentin and CD10 in RCC cells. Patient samples were collected in duplicate CellSaveTM tubes and processed one day later. A CD10+/vimentin+/CD45- cell population was detected in blood samples with enumeration ranging from 4 to 86 cells/7.5 mL of blood. We found that the RCC CTC profile was distinct from other types of cancers. The typical CTCs display abnormal morphology, including large nuclei (typically 15-30 µm in size), irregular cell size and shape, and high nucleus-to-cytoplasm ratio. Although CD10 and vimentin antibodies have cross-reactivity with white blood cells (WBC), the CTCs could be distinguished from WBC based on morphology, cell size and CD45- staining. Conclusions: We demonstrated that the CellSieveTM microfiltration assay is a very simple and efficient method to isolate a CD10+/vimentin+/CD45- cell population from patients affected by metastatic ccRCC. Future studies include fluorescence in situ hybridization to confirm loss of 3p, a molecular event that occurs in >90% of ccRCC. We are also analyzing blood samples from patients treated with tyrosine kinase inhibitors to determine if cell enumeration is predictive of response to treatment. This technology might greatly facilitate detection of EpCAM negative ccRCC CTCs. The clinical significance of these unusual, large, rod-shaped, naked nuclei require further molecular characterization. Citation Format: Peixuan Zhu, Thai Ho, Erik P. Castle, Richard W. Joseph, Melissa L. Stanton, Shuhong Li, Daniel Adams, Olga V. Makarova, Platte T. Amstutz, Cha-Mei Tang. Isolation and identification of circulating tumor cells in renal cell carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3081. doi:10.1158/1538-7445.AM2014-3081

Hidradenocarcinoma is a rare malignancy of the sweat glands with only a few cases reported in literature. The management of these tumors is based on the extent of disease with local disease managed with surgical resection. These can tumors carry a high potential of lymphatic and vascular spread and local and distant metastases are not uncommon. Given the rarity of the tumor and lack of genetic and clinical data about these tumors, there is no consensus on the proper management of metastatic disease. Here in we report the first case of metastatic hidradenocarcinoma with detailed molecular profiling including whole exome sequencing. We identified mutations in multiple genes including two that are potentially targetable: PTCH1 and TCF7L1. Further work is necessary to not only confirm the presence of these mutations but also to confirm the clinical significance.

Abstract Therapies that activate the immune system through blocking the binding of programmed death ligand 1 (PD-L1) present on tumors and PD-1 (programmed death 1) present on activated immune cells are revolutionizing the care for patients with cancer. These therapies work by inhibiting negative regulators of the immune system, thereby decreasing a tumor's ability to evade the immune system. The side effects of anti–PD-1/PD-L1 therapies are generally mild and as expected are related to autoimmune reactions. Two of the most common side effects of anti–PD-1/PD-L1 therapies are rash and pruritus occurring in approximately 20% of patients. Although the rash is generally recognized to be immune mediated, the exact mechanisms of the rash remain unclear. Herein, we report three cases of lichenoid dermatitis in three patients treated with MK-3475 (anti–PD-1) that were characterized with marked T-cell infiltrates with few PD-1–positive cells. The rashes in all three patients were relatively mild, allowing treatment to continue despite the rashes. Cancer Immunol Res; 3(1); 18–22. ©2014 AACR.