814 Background: Dihydropyrimidine dehydrogenase (DPD), encoded by the DPYD gene, metabolizes 5-fluorouracil (5FU). DPD deficiency due to DPYD variants can cause severe drug-related toxicities. Most genomic studies focus on populations of European (EUR) genetic ancestry, underscoring the need for broader ancestral representation. Methods: Using Natera’s Real-World Database, we analyzed clinicogenomic data from 228,239 solid tumor patients who underwent Signatera ctDNA testing (2019–2025). Whole-exome sequencing and ancestry inference (EthSeq) grouped patients into EUR, African (AFR), East Asian (EAS), and South Asian (SAS) cohorts. DPYD variants were annotated using VEP (v1.1.4, GRCh37) and classified as Tier 1/2 per AMP guidelines. Results: After excluding cancer types not treated with 5FU (lung, N=8,711; melanoma, N=7,600), the most common cancer types were CRC (N=106,839; 47.3%), breast (N=54,410; 24.1%), and bladder (N=8,154; 3.6%). The cohort was predominantly EUR (183,842; 81.3%), followed by AFR (24,117; 10.7%), EAS (10,882; 4.8%), and SAS (3,285; 1.5%). A total of 1,789 DPYD variants (1,603 loci) were detected. Fourteen unique Tier 1/2 variants (13 loci) were detected in 5.0% of patients (99.3% heterozygous). Combined Tier 1/2 frequencies were similar for EUR (5.2%) and AFR (5.4%), but markedly lower in EAS (0.7%), with individual variants displaying strong divergence between ancestry groups (top variants listed in the table). Conclusions: This study, which includes a substantial number of patients from ancestries often underrepresented in genomic research (>3,000 SAS, >10,000 EAS, and >24,000 AFR), reveals marked differences in the prevalence of clinically relevant DPYD variants across populations. The higher frequency of certain individual variants in AFR patients underscores the limitations of current pharmacogenetic testing panels optimized largely based on EUR cohorts. These findings support broader ancestry-informed pharmacogenetic screening to reduce 5FU toxicity risk across diverse populations. Prevalence of top tier 1/2 variants across ancestry groups. Variant ID Tier All EUR AFR EAS rs56038477 1 2.97% 3.42% 0.70% 0.15% rs67376798 1 0.89% 1.04% 0.26% 0.09% rs3918290 1 0.47% 0.54% 0.09% 0.02% rs115232898 1 0.46% 0.06% 3.79% 0.03% rs55886062 1 0.10% 0.11% 0.03% 0.00% rs146356975 1 0.06% 0.01% 0.54% 0.01% rs72549309 2 0.03% 0.03% 0.01% 0.00% rs59086055 2 0.02% 0.01% 0.01% 0.26%

Emerging technologies focused on the detection and quantification of circulating tumor DNA (ctDNA) in blood show extensive potential for managing patient treatment decisions, informing risk of recurrence, and predicting response to therapy. Currently available tissue-informed approaches are often limited by the need for additional sequencing of normal tissue or peripheral mononuclear cells to identify non-tumor-derived alterations while tissue-naïve approaches are often limited in sensitivity. Here we present the analytical validation for a novel ctDNA monitoring assay, FoundationOne®Tracker. The assay utilizes somatic alterations from comprehensive genomic profiling (CGP) of tumor tissue. A novel algorithm identifies monitorable alterations with a high probability of being somatic and computationally filters non-tumor-derived alterations such as germline or clonal hematopoiesis variants without the need for sequencing of additional samples. Monitorable alterations identified from tissue CGP are then quantified in blood using a multiplex polymerase chain reaction assay based on the validated SignateraTM assay. The analytical specificity of the plasma workflow is shown to be 99.6% at the sample level. Analytical sensitivity is shown to be >97.3% at ≥5 mean tumor molecules per mL of plasma (MTM/mL) when tested with the most conservative configuration using only two monitorable alterations. The assay also demonstrates high analytical accuracy when compared to liquid biopsy-based CGP as well as high qualitative (measured 100% PPA) and quantitative precision (<11.2% coefficient of variation).

Supplementary Figure S1 and Supplementary Tables S1-S2. Supplementary Figure S1. Diagram of tissue block usage for CNB Development Study and Chemo-prediction Validation Study. Supplemental Table S1. Top-10 and bottom-10 Prosigna gene-correlations between paired CNBs and SRS. Supplemental Table S2. Distribution of the Prosigna subtypes within the three main pathology-based groups in 39 independent metastatic samples.

Distal ulna plate fixation for ulnar neck and head fractures (excluding ulnar styloid fractures) aims to anatomically reduce the distal ulna fracture (DUF) by open reduction and internal fixation, while obtaining a stable construct allowing functional rehabilitation without need for cast immobilization. Severe displacement, angulation or translation, as well as unstable or intra-articular fractures. Furthermore, multiple trauma or young patients in need of quick functional rehabilitation. Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation. Stable, nondisplaced fractures. Need for bridging plate or external fixator of distal radiocarpal joint. An ulnar approach, with a straight incision between the extensor and flexor carpi ulnaris. Preservation of the dorsal branch of the ulnar nerve. Reduction and plate fixation with avoidance of plate impingement in the articular zone. Postoperatively, an elastic bandage is applied for the first 24–48 h. In isolated DUF with stable fixation, a postoperative splint is often unnecessary and should be avoided. For the first four weeks, only light weightbearing of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be increased as tolerated. The best available evidence likely shows that for younger patients with a DUF, with or without concomitant distal radius fractures, open reduction and internal fixation can be safely achieved with good functional outcome and acceptable union and complication rates as long as proper technique is ensured.

<p>PDF file - 34K, Supplementary Table S1. ROR cutoff values for risk groups defined by nodal status.</p>

Abstract Objectives Distal ulna plate fixation for ulnar neck and head fractures (excluding ulnar styloid fractures) aims to anatomically reduce the distal ulna fracture (DUF) by open reduction and internal fixation, while obtaining a stable construct allowing functional rehabilitation without need for cast immobilization. Indications Severe displacement, angulation or translation, as well as unstable or intra-articular fractures. Furthermore, multiple trauma or young patients in need of quick functional rehabilitation. Contraindications Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation. Stable, nondisplaced fractures. Need for bridging plate or external fixator of distal radiocarpal joint. Surgical technique An ulnar approach, with a straight incision between the extensor and flexor carpi ulnaris. Preservation of the dorsal branch of the ulnar nerve. Reduction and plate fixation with avoidance of plate impingement in the articular zone. Postoperative management Postoperatively, an elastic bandage is applied for the first 24–48 h. In isolated DUF with stable fixation, a postoperative splint is often unnecessary and should be avoided. For the first four weeks, only light weightbearing of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be increased as tolerated. Results The best available evidence likely shows that for younger patients with a DUF, with or without concomitant distal radius fractures, open reduction and internal fixation can be safely achieved with good functional outcome and acceptable union and complication rates as long as proper technique is ensured.

Abstract Objective The treatment of complex proximal humerus fractures in elderly patients is not yet fully eluci-dated. Of all treatment options reverse shoulder arthroplasty (RSA) and non operative treat-ment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus non-operative treatment. Methods Studies comparing RSA and NOT were included for direct comparison by systematic re-view and pooled analysis for patient rated outcome and range of motion. Additionally, indirect comparison of case-series and non-comparative studies on either treatment modalities was performed separately. Results Comparative: Reverse shoulder arthroplasty resulted in better patient rated outcome scores and better range of motion. Pain and treatment satisfaction scores were better after RSA. Non comparative studies reported similar patient rated and range of motion scores for both RSA and after NOT. Conclusion The functional and range of motion outcomes after RSA seem satisfactory and potentially superior to NOT in elderly patients. The complication rate is acceptably low and an overall revision rate of 5% was found. These results should however be viewed in light of distinct differences in patient characteristics between treatment groups.

Background The aim of this study was to investigate whether the PAM-50-based 46-gene assay carries prognostic value for risk of local recurrence of breast cancer. Methods The Austrian Breast and Colorectal Cancer Study Group (ABCSG) 8 RCT compared 5 years of tamoxifen with tamoxifen for 2 years followed by anastrozole for 3 years in postmenopausal women with endocrine receptor-positive breast cancer. This study included patients from the trial who had breast-conserving surgery for whom tumour blocks were available for PAM-50 analysis. Results Tumour blocks from 1204 patients who had breast-conserving surgery were available for the PAM-50 analysis, and 1034 of these received radiotherapy. After a median follow-up of 10.8 years, 23 local events had been observed, corresponding to an overall local recurrence risk of 2.2 per cent. Univariable competing-risk analysis demonstrated that patients at low risk according to PAM-50 analysis (risk-of-recurrence (ROR) score less than 57) had a significantly lower incidence of local recurrence than those in the high-risk group at 5 years (0.1 (95 per cent c.i. 0 to 0.7) versus 2.2 (0.9 to 4.6) per cent respectively; subhazard ratio (SHR) 17.18, 95 per cent c.i. 2.06 to 142.88; P = 0.009) and 10 years (0.9 (0.4 to 2.0) versus 3.8 (1.9 to 6.6) per cent; SHR 4.76, 1.72 to 13.17; P = 0.003). Multivariable analyses that included ROR score, age, tumour size, nodal status, type of surgery, tumor grade, and trial-specific endocrine therapy confirmed that ROR score was an independent prognostic factor for risk of local recurrence. Analysis of the women randomized to radiotherapy or control after breast conservation showed that PAM-50 was not predictive of radiotherapy effect. Conclusion PAM-50 can be used as a prognostic tool for local recurrence risk in postmenopausal women with hormone receptor-positive breast cancer treated with endocrine therapy. The test was not predictive for the benefit of radiotherapy.

Un metodo para determinar el riesgo de recurrencia bajo o alto (ROR) en un sujeto que tiene cancer de mama que comprende: determinar el tamano del tumor de cancer de mama del sujeto; determinar un valor de correlacion de un tumor de cancer de mama para cada uno de al menos cuatro subtipos intrinsecos, que incluyen un tipo Basal, Luminal A, Luminal B o HER-2 enriquecido, midiendo la expresion de ARN de al menos 40 de los genes en la lista de genes intrinsecos NANO46 de la Tabla 1; determinar una puntuacion de proliferacion midiendo la expresion de ARN de cada uno de los subconjuntos de 18 genes de los genes intrinsecos NANO46 seleccionados de ANLN, CCNE1, CDC20, CDC6, CDCA1, CENPF, CEP55, EXO1, KIF2C, KNTC2, MELK, MKI67, ORC6L, PTTG1, RRM2, TYMS, UBE2C y UBE2T; calcular una puntuacion de riesgo de recurrencia (ROR) con el uso de la siguiente ecuacion: ROR-PT = - 0,0067*Basal + 0,4317*Her2 + -0,3172*LumA + 0,4894*LumB + 0,1981*Puntuacion de proliferacion + 0,1133*Tamano de tumor; en donde la puntuacion de riesgo de recurrencia es un valor entero en una escala de 0- 100, en donde el nivel de expresion de ARN para almenos 40 de los genes en la lista de genes intrinsecos NANO46 de la Tabla 1 se muestran en la Tabla 3; determinar de ese modo si el sujeto tiene un riesgo de recurrencia bajo o alto en funcion de la puntuacion de riesgo de recurrencia (ROR) y la interpretacion de la puntuacion ROR con el uso de la clasificacion de riesgo mediante el intervalo de riesgo de recurrencia (ROR) y estado nodular.

Abstract Background: Oncotype DX Recurrence Score (RS), Prosigna PAM50 ROR score, the EndoPredict score (EP, EPclin) and the Breast Cancer Index (BCI) all provide substantial molecular prognostic information and are used in clinical practice for guiding the treatment for large numbers of patients with primary ER+/HER2- breast cancer. Despite this, there is incomplete information on the concordance between these scores and very little understanding of the molecular features that drive the individual scores. Here we report from a unique database (i) the correlation between all 4 scores when measured by the respective manufacturers in the TransATAC set of samples and (ii) the degree to which each of the scores is driven by proliferation, oestrogen signalling, HER2 signalling and invasive properties insomuch as these are reflected by each component module of the RS test (PM, EM, HM and IM, respectively). Methods: The TransATAC tumour sample set was collected from patients in the tamoxifen or anastrozole arms from the ATAC clinical trial of 5 years of endocrine therapy in postmenopausal patients with primary hormone receptor positive breast cancer. Cases were included if HER2- and all 4 scores were available. None of the patients received adjuvant chemotherapy. EP and ROR both include some clinical features in their final score but components were excluded for the purposes of this study. The RS module scores were provided by the manufacturer. The genes that contribute to the module scores are as follows: PM: Ki67, STK15, Survivin, CCNB1, MYBL2; EM: ER, PGR, BCL2, SCUBE2; HM: GRB7, HER2; IM: MMP11, CTSL2). Spearman rank correlation was used to study the association between molecular components. Results: Data was available for all four molecular scores for 785 TransATAC patients. Correlations were moderate to strong for RS vs EP (r=0.63), ROR vs EP (r=0.68), ROR vs BCI (r=0.74) and EP vs BCI (r=0.67) but were weak for RS vs ROR (r=0.32) and RS vs BCI (r=0.35). The correlation between each score with the RS module scores are shown in the Table. Molecular scoreRS moduleRSROREPBCIPM0.360.860.710.74EM-0.790.00-0.38-0.10HM-0.04-0.14-0.15-0.18IM0.260.380.340.32 The RS had a strong negative correlation with its EM (r= -0.79) and a weak positive correlation with its PM (r= 0.36) although the latter was stronger when the PM was thresholded; 78% of the cases had a PM score below the threshold of 6.5 and were assigned a value of 6.5 in the RS with no correlation between RS and PM in these samples (r=-0.03). ROR showed a very strong correlation with the PM (r=0.86), but none with the EM (r: 0.00). EP and BCI both showed strong correlation with the PM (r= 0.71 and 0.74, respectively) and with low or near absent correlation with EM (r= -0.38 and -0.10, respectively). There was little correlation between the HM with each of the scores while the IM correlation was similar for each score varying from 0.26 to 0.38. Of the two module components of BCI, MGI was strongly associated with the PM (r= 0.84) and not at all with the EM while H/I moderately correlated with PM (r=0.51) and weakly correlated with EM (r= -0.31). Conclusion: EP scores are moderately correlated with each of the other 3 scores while RS scores are dissimilar to those from the ROR and BCI. In contrast to common thinking the RS is driven only weakly by proliferative features and more by those related to ER/PR pathways. The EP, BCI and particularly ROR are dominated by proliferative features. These relationships provide and explanation for the differences that we and others have reported in the prognostic performance of the tests for both early and late recurrence. Citation Format: Richard Buus, Ivana Sestak, Mitch Dowsett, Ralf Kronenwett, Sean Ferree, Catherine Schnabel, Frederick L Baehner, Jack Cuzick. Correlation between and molecular drivers of oncotype DX, prosigna, EndoPredict and breast cancer index: A TransATAC study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-07-05.

PURPOSE The Oncotype DX Recurrence Score (RS), Prosigna Prediction Analysis of Microarray 50 (PAM50) Risk of Recurrence (ROR), EndoPredict (EP), and Breast Cancer Index (BCI) are used clinically for estimating risk of distant recurrence for patients receiving endocrine therapy. Discordances in estimates occur between them. We aimed to identify the molecular features that drive the tests and lead to these differences. PATIENTS AND METHODS Analyses for RS, ROR, EP, and BCI were conducted by the manufacturers in the TransATAC sample collection that consisted of the tamoxifen or anastrozole arms of the ATAC trial. Estrogen receptor–positive/human epidermal growth factor receptor 2 (HER2)–negative cases without chemotherapy treatment were included in which all four tests were available (n = 785). Clinicopathologic features included in some tests were excluded from the comparisons. Estrogen, proliferation, invasion, and HER2 module scores from RS were used to characterize the respective molecular features. Spearman correlation and analysis of variance tests were applied. RESULTS There were moderate to strong correlations among the four molecular scores (ρ = 0.63-0.74) except for RS versus ROR (ρ = 0.32) and RS versus BCI (ρ = 0.35). RS had strong negative correlation with its estrogen module (ρ = −0.79) and moderate positive correlation with its proliferation module (ρ = 0.36). RS’s proliferation module explained 72.5% of ROR’s variance, while the estrogen module explained only 0.6%. Most of EP’s and BCI’s variation was accounted for by the proliferation module (50.0% and 54.3%, respectively) and much less by the estrogen module (20.2% and 2.7%, respectively). CONCLUSION In contrast to common understanding, RSs are determined more strongly by estrogen-related features and only weakly by proliferation markers. However, the EP, BCI, and particularly ROR scores are determined largely by proliferative features. These relationships help to explain the differences in the prognostic performance of the tests.

PURPOSE:The Prosigna-PAM50 risk of recurrence (ROR) score has documented clinical utility for the prediction of 10-year distant recurrence (DR). The present study investigated the value of Prosigna-PAM50 for predicting 10-year DR and overall survival after 5 years of endocrine treatment for postmenopausal patients with invasive lobular carcinoma.PATIENTS AND METHODS:Using the Danish Breast Cancer Group database, we identified patients with a diagnosis from 2000 to 2003 of estrogen receptor-positive, human epidermal growth factor receptor 2-negative invasive ductal (n = 1570) or lobular (n = 341) cancer > 20 mm or 1 to 3 positive lymph nodes and applied multivariate Cox models.RESULTS:The median follow-up for DR was 9.3 years and for overall survival 15.2 years. Of the 341 lobular and 1570 ductal cases, 140 (41%) and 349 (22%) were classified as low ROR, with a 10-year DR rate of 7.7% (95% confidence interval [CI], 3.7%-13.6%) and 3.5% (95% CI, 1.8%-6.2%), respectively. The 10-year DR rate for the intermediate ROR group for those with lobular cancer was 18% (95% CI, 10.1%-27.9%) compared with 9.7% (95% CI, 6.7%-13.4%) for those with ductal cancer. Luminal B tumors had a significantly worse outcome than luminal A tumors in both lobular (hazard ratio, 1.89; 95% CI, 1.03%-3.45%; P = .04) and ductal (hazard ratio, 3.18; 95% CI, 2.29%-4.43%; P < .0001) cancer.CONCLUSION:Prosigna PAM-50 provides significant prognostic information beyond the clinicopathologic factors in patients with invasive lobular breast cancer. Those with lobular cancer had worse 10-year DR rates compared with those with ductal cancer in the same ROR category. Our results could have an effect on the treatment decisions regarding the addition of chemotherapy for those in the intermediate ROR group.

The DBCG89D trial randomized high-risk early breast cancer patients to adjuvant CMF (cyclophosphamide, methotrexate and fluorouracil) or CEF (cyclophosphamide, epirubicin and fluorouracil). Prosigna assays were performed by researchers with no access to clinical data. Time to distant recurrence (DR) was the primary endpoint, time to recurrence (TR) and overall survival (OS) secondary. Among the 980 Danish patients enrolled, Prosigna results were obtained in 686. Continuous ROR score was associated with DR for CMF (adjusted hazard ratio (HR) 1.20, 95% CI 1.09–1.33), and for CEF (HR 1.04, 95% CI 0.92–1.18), P interaction = 0.06. DR was significantly longer in CEF compared to CMF treated patients with Her2-enriched tumors (HR 0.58, 95% CI 0.38–0.86), but not in patients with luminal tumors. Heterogeneity of treatment effect was significant for TR and OS. In this prospective-retrospective analysis, patients with Her2-enriched breast cancer derived substantial benefit from anthracycline chemotherapy whereas anthracyclines are not an essential component of chemotherapy for patients with luminal subtypes. The benefit of CEF vs. CMF correlated with increasing ROR Score.

Abstract Background: Several multigene assays are available for managing ER-positive, HER2-negative early stage breast cancer but with little direct comparative information within this patient population. Existing evidence suggests that current multigene assays provide broadly equivalent risk information for the population of women with ER-positive, HER2-negative breast cancers. However, for the individual patient tests may provide differing risk categorization (Bartlett et al, JNCI 2016). We have previously demonstrated the prognostic value of different commercially available tests including Prosigna (ROR) and Oncotype Dx (RS) (Dowsett et al, JCO 2013; Sestak et al, JAMA Onc 2018). Here, we investigate risk classification and 10-year DR rates in patients that had discordant risk categorization between ROR and RS. Methods: A total of 663 postmenopausal women with ER-positive, HER2-negative, node-negative early stage breast cancer from the TransATAC study for whom both signatures were available were included in this analysis. The primary endpoint was distant recurrence (DR). Predefined ROR cut-off points for low/intermediate and intermediate/high of 40/60 were used. Comparisons were made using two sets of RS cut-off points 1) TailoRX cut-off points of 10/25 and 2) original cut-off points of 18/31. Kaplan-Meier curves were used to estimate the mean risk of DR after 10 years of follow-up in predefined risk groups. Results: Using original RS cut-off points, 25 patients (3.8%) had a high-low discordance compared to ROR, with a total of 295 (44.5%) discordant cases. Using the TailoRx cut-off points, 40 patients (6.0%) had a high-low discordance compared to ROR, with a total of 396 (59.7%) discordant cases. Applying original RS cut-off points, patients categorized into ROR low but into intermediate or high by RS (86/365 (23.6%)) had a 10-year DR rate of only 6.3% (2.7-14.6) (Table). In contrast, patients categorized into RS low but into intermediate or high by ROR (144/423 (48.6%)) had a 10-year DR rate of 13.4% (8.3-21.2). Using the TailoRx cut-off points, patients categorized into ROR low but into intermediate or high by RS (261/365 (71.5%)) had a 10-year DR rate of 2.9% (1.4-5.9), while patients with an RS low but intermediate or high by ROR (62/166 (37.3%)) had a 10-year DR rate of 18.2% (10.2-31.2) (Table). Conclusion: Discordance in risk categorization at the individual patient-level between commercially available multigene assays for early stage breast cancer is not uncommon. Our results show that node-negative patients that were classified by ROR as low risk, regardless of RS risk stratification, had an excellent 10-year DR risk with endocrine therapy alone. In contrast, patients that were classified as RS low risk by either cut-off points but were classified as intermediate or high risk by ROR had a significantly worse 10-year outcome. Our results indicate that ROR better categorized women with node negative disease into respective risk groups. Risk stratification and 10-year DR risk (%) according to ROR and RS cut-off points.ROR cut-offsLow (N=365)Intermediate/High(N=298)Original RS cut-offsNumber10-year risk (%)Number10-year risk (%)Low (N=423)2791.5%14413.4%Intermediate/High (N=240)866.3%15424.8%TailoRx cut-offsLow (N=166)1042.1%6218.2%Intermediate/High (N=497)2612.9%23619.5% Citation Format: Ivana Sestak, Sean Ferree, Itay Shemesh, Wesley Buckingham, Jack Cuzick, Mitchell Dowsett. Discordant classification and outcomes between Prosigna and Oncotype Dx Recurrence Score for ER-positive, HER2-negative, node-negative breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-06-05.

Clinical benefit from checkpoint inhibitors has been associated in a tumor-agnostic manner with two main tumor traits. The first is tumor antigenicity, which is typically measured by tumor mutation burden, microsatellite instability (MSI), or Mismatch Repair Deficiency using gene sequence platforms and/or immunohistochemistry. The second is the presence of a pre-existing adaptive immune response, typically measured by immunohistochemistry (e.g. single analyte PD-L1 expression) and/or gene expression signatures (e.g. tumor “inflamed” phenotype). These two traits have been shown to provide independent predictive information. Here we investigated the potential of using gene expression to predict tumor MSI, thus enabling the measurement of both tumor antigenicity and the level of tumor inflammation in a single assay, possibly reducing sample requirement, turn-around time, and overall cost.