[Grading of gynecological tumors : Current aspects]

Histopathological assessment of the tumor grade and cell type is central to the management and prognosis of various gynecological malignancies. Conventional grading systems for squamous carcinomas and adenocarcinomas of the vulva, vagina and cervix are poorly defined. For endometrioid tumors of the female genital tract as well as for mucinous endometrial, ovarian and seromucinous ovarian carcinomas, the 3‑tiered FIGO grading system is recommended. For uterine neuroendocrine tumors the grading system of the gastrointestinal counterparts has been adopted. Uterine leiomyosarcomas are not graded. Endometrial stromal sarcomas are divided into low and high grades, based on cellular morphology, immunohistochemical and molecular findings. A chemotherapy response score was established for chemotherapeutically treated high-grade serous pelvic cancer. For non-epithelial ovarian malignancies, only Sertoli-Leydig cell tumors and immature teratomas are graded. At this time molecular profiling has no impact on the grading of tumors of the female genital tract.

Dietary practices in isovaleric acidemia: A European survey

Background

In Europe, dietary management of isovaleric acidemia (IVA) may vary widely. There is limited collective information about dietetic management.

Aim

To describe European practice regarding the dietary management of IVA, prior to the availability of the E-IMD IVA guidelines (E-IMD 2014).

Methods

A cross-sectional questionnaire was sent to all European dietitians who were either members of the Society for the Study of Inborn Errors of Metabolism Dietitians Group (SSIEM-DG) or whom had responded to previous questionnaires on dietetic practice (n = 53). The questionnaire comprised 27 questions about the dietary management of IVA.

Results

Information on 140 patients with IVA from 39 centres was reported. 133 patients (38 centres) were given a protein restricted diet. Leucine-free amino acid supplements (LFAA) were routinely used to supplement protein intake in 58% of centres. The median total protein intake prescribed achieved the WHO/FAO/UNU [2007] safe levels of protein intake in all age groups. Centres that prescribed LFAA had lower natural protein intakes in most age groups except 1 to 10 y. In contrast, when centres were not using LFAA, the median natural protein intake met WHO/FAO/UNU [2007] safe levels of protein intake in all age groups. Enteral tube feeding was rarely prescribed.

Conclusions

This survey demonstrates wide differences in dietary practice in the management of IVA across European centres. It provides unique dietary data collectively representing European practices in IVA which can be used as a foundation to compare dietary management changes as a consequence of the first E-IMD IVA guidelines availability.

Abstract P2-05-23: EP3-receptor expression is a prognostic marker for overall survival and progression-free survival in sporadic breast cancer

Aim: Prostaglandins are tissue hormones with a variety of biological effects and are mainly associated with infection and inflammation. However, elevated prostaglandin synthesis, especially of prostaglandin E2 (PGE2) caused by overexpression of cyclooxygenase-2 (COX-2), has also been associated with the development and progression of different kinds of cancer. Clinical trials have shown the potential of non-steroidal anti-inflammatory drugs or specific COX-2 inhibitors (coxibs) in prevention and treatment of malignant disease, as they reduce prostaglandin levels via inhibition of COX-2. Unfortunately, the clinical use of these drugs is limited due to their various side effects. PGE2 exerts its effects by signaling through four specific membrane-bound receptors, the EP-receptors 1-4. In recent research, the relevance of EP-receptors in carcinogenesis is investigated in the attempt to find a more specific target for the reduction of prostaglandin-effects without inducing side effects. This study evaluates the expression of EP3-receptor on breast cancer tissue and its correlation to progression and survival

Material and methods: A total of 277 sporadic breast cancer samples without primary distant metastases were immunohistochemically analyzed for EP3-receptor expression. Tissue samples were stained with primary anti-EP3 antibodies (monoclonal rabbit IgG). EP3-receptor-expression was quantified by the semi-quantitative immunoreactivity score (IRS); samples with an IRS ≥ 2 were scored as EP3 positive. Statistical analyses were performed with SPSS software using chi-squared test as well as Kaplan-Meier-estimates and Cox regression for survival analyses.

Results: EP3-receptor was expressed in 71.1 % of all cases. EP3-receptor expression did not correlate with clinicopathological parameters such as tumor size or lymph node status at primary diagnosis or with the expression of other immunohistochemical markers (estrogen and progesterone receptor, Her2). Distant metastasis occurred in 49.1 % of EP3 negative cases but only in 32.8 % of EP3 positive cases in an observation period of up to ten years (p = 0.03). EP3 receptor positive cases also showed significantly improved progression-free survival rates (overall [p = 0.01], ten years [p = 0.002] and five years [p = 0.04]). Furthermore, EP3-receptor positivity was associated with an improved overall survival rate (p = 0.002) and ten years survival rate (p = 0.001), whereas short-time survival rate (five years) did not differ between both EP3-groups (p = 0.10). In a multivariate analysis comparing all factors with significant influence in univariate testing, EP3-receptor could be confirmed as an independent factor.

Discussion: Our results show that EP3-receptor positivity is a relevant prognostic factor in sporadic breast cancer. Its correlation with a favorable course of disease is especially interesting as EP3 is known to regulate uPA, a well-known parameter which is – on the contrary - associated with unfavorable survival in breast cancer. Therefore, ongoing studies by our group aim to examine the correlation of EP3-receptor to the uPA/PAI1-pathway and to evaluate the possibility to target EP3-receptor in future anti-tumor therapy in breast cancer.

Citation Format: Semmlinger A, von Schönfeldt V, Wolf V, Schmoeckel E, Mayr D, Meuter A, Mahner S, Jeschke U, Ditsch N. EP3-receptor expression is a prognostic marker for overall survival and progression-free survival in sporadic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-23.

Targeting the actin cytoskeleton: selective antitumor action via trapping PKCɛ

Targeting the actin cytoskeleton (CSK) of cancer cells offers a valuable strategy in cancer therapy. There are a number of natural compounds that interfere with the actin CSK, but the mode of their cytotoxic action and, moreover, their tumor-specific mechanisms are quite elusive. We used the myxobacterial compound Chondramide as a tool to first elucidate the mechanisms of cytotoxicity of actin targeting in breast cancer cells (MCF7, MDA-MB-231). Chondramide inhibits cellular actin filament dynamics shown by a fluorescence-based analysis (fluorescence recovery after photobleaching (FRAP)) and leads to apoptosis characterized by phosphatidylserine exposure, release of cytochrome C from mitochondria and finally activation of caspases. Chondramide enhances the occurrence of mitochondrial permeability transition (MPT) by affecting known MPT modulators: Hexokinase II bound to the voltage-dependent anion channel (VDAC) translocated from the outer mitochondrial membrane to the cytosol and the proapoptotic protein Bad were recruited to the mitochondria. Importantly, protein kinase C-ɛ (PKCɛ), a prosurvival kinase possessing an actin-binding site and known to regulate the hexokinase/VDAC interaction as well as Bad phosphorylation was identified as the link between actin CSK and apoptosis induction. PKCɛ, which was found overexpressed in breast cancer cells, accumulated in actin bundles induced by Chondramide and lost its activity. Our second goal was to characterize the potential tumor-specific action of actin-binding agents. As the nontumor breast epithelial cell line MCF-10A in fact shows resistance to Chondramide-induced apoptosis and notably express low level of PKCɛ, we suggest that trapping PKCɛ via Chondramide-induced actin hyperpolymerization displays tumor cell specificity. Our work provides a link between targeting the ubiquitously occurring actin CSK and selective inhibition of pro-tumorigenic PKCɛ, thus setting the stage for actin-stabilizing agents as innovative cancer drugs. This is moreover supported by the in vivo efficacy of Chondramide triggered by abrogation of PKCɛ signaling shown in a xenograft breast cancer model.

Quantitative breast tissue characterization using grating-based x-ray phase-contrast imaging

X-ray phase-contrast imaging has received growing interest in recent years due to its high capability in visualizing soft tissue. Breast imaging became the focus of particular attention as it is considered the most promising candidate for a first clinical application of this contrast modality. In this study, we investigate quantitative breast tissue characterization using grating-based phase-contrast computed tomography (CT) at conventional polychromatic x-ray sources. Different breast specimens have been scanned at a laboratory phase-contrast imaging setup and were correlated to histopathology. Ascertained tumor types include phylloides tumor, fibroadenoma and infiltrating lobular carcinoma. Identified tissue types comprising adipose, fibroglandular and tumor tissue have been analyzed in terms of phase-contrast Hounsfield units and are compared to high-quality, high-resolution data obtained with monochromatic synchrotron radiation, as well as calculated values based on tabulated tissue properties. The results give a good impression of the method's prospects and limitations for potential tumor detection and the associated demands on such a phase-contrast breast CT system. Furthermore, the evaluated quantitative tissue values serve as a reference for simulations and the design of dedicated phantoms for phase-contrast mammography.

Abstract P3-12-12: Body mass index does not influence febrile neutropenia and delivered dose intensity in adjuvant chemotherapy for breast cancer

Background

Obese patients are often not fully dosed when receiving adjuvant chemotherapy for breast cancer, which might influence the inferior outcomes seen in this patient population. Current guidelines recommend full, weight-based dosing of chemoherapy for obese patients. The aim of the present study was to assess toxicity and deliverable dose intensity in patients treated with adjuvant chemotherapy for breast cancer.

Patients and Methods

We conducted a single-center retrospective case review on patients treated with adjuvant chemotherapy for early breast cancer at our institution from 2009 to 2012. Data were extracted from electronic patient records and side effect were graded according to CTC AE 3.0 in the source data.

Statistics: Chi-Square, Fisher's exact test, MANOVA and repeated measures ANOVA. Software: SPSS 18.

The study received approval from the local ethics comitee.

Results

We included 187 patients (185 female, 2 male) who received a total of 924 courses of chemotherapy with full eight-based dosing with either 6 courses of FEC-T (n = ,%) or TC (n = ,%). There were no differences accross BMI categories for age, gender, endocrine receptor expression, grading or her2-status.

Obese patients had more unplanned admission (p = 0.008), infections (grade 3-4, p = 0.005, all grades, p = 0.025) and diarrhoe (all grades, p = 0.033) compared to normal-weight patients. This was not the case for overweight patients (p = 0.063, 0.322, 0.199, 0.107, 0.065). Obese and overweight patients had more constipation than normal-weight patients (all grades, p = 0.025 and 0.006, respectively). There were no signficant differences across weight categories for neutropenic fever, delivered dose intensity, dose reduction and premature discontinuation of therapy.

Discussion

Obese and overweight patients can be treated with full dose intensity and do not suffer from excessive serious complications compared to normal-weight patients. However, due to partly increased toxicity seen in obese patients, adequate supportive therapy is of particular importance.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-12-12.

The EndoPredict score provides prognostic information on late distant metastases in ER+/HER2- breast cancer patients

Background:

ER+/HER2− breast cancers have a proclivity for late recurrence. A personalised estimate of relapse risk after 5 years of endocrine treatment can improve patient selection for extended hormonal therapy.

Methods:

A total of 1702 postmenopausal ER+/HER2− breast cancer patients from two adjuvant phase III trials (ABCSG6, ABCSG8) treated with 5 years of endocrine therapy participated in this study. The multigene test EndoPredict (EP) and the EPclin score (which combines EP with tumour size and nodal status) were predefined in independent training cohorts. All patients were retrospectively assigned to risk categories based on gene expression and on clinical parameters. The primary end point was distant metastasis (DM). Kaplan–Meier method and Cox regression analysis were used in an early (0–5 years) and late time interval (>5 years post diagnosis).

Results:

EP is a significant, independent, prognostic parameter in the early and late time interval. The expression levels of proliferative and ER signalling genes contribute differentially to the underlying biology of early and late DM. The EPclin stratified 64% of patients at risk after 5 years into a low-risk subgroup with an absolute 1.8% of late DM at 10 years of follow-up.

Conclusion:

The EP test provides additional prognostic information for the identification of early and late DM beyond what can be achieved by combining the commonly used clinical parameters. The EPclin reliably identified a subgroup of patients who have an excellent long-term prognosis after 5 years of endocrine therapy. The side effects of extended therapy should be weighed against this projected outcome.

EndoPredict improves the prognostic classification derived from common clinical guidelines in ER-positive, HER2-negative early breast cancer

BACKGROUND

In early estrogen receptor (ER)-positive/HER2-negative breast cancer, the decision to administer chemotherapy is largely based on prognostic criteria. The combined molecular/clinical EndoPredict test (EPclin) has been validated to accurately assess prognosis in this population. In this study, the clinical relevance of EPclin in relation to well-established clinical guidelines is assessed.

PATIENTS AND METHODS

We assigned risk groups to 1702 ER-positive/HER2-negative postmenopausal women from two large phase III trials treated only with endocrine therapy. Prognosis was assigned according to National Comprehensive Cancer Center Network-, German S3-, St Gallen guidelines and the EPclin. Prognostic groups were compared using the Kaplan-Meier survival analysis.

RESULTS

After 10 years, absolute risk reductions (ARR) between the high- and low-risk groups ranged from 6.9% to 11.2% if assigned according to guidelines. It was at 18.7% for EPclin. EPclin reassigned 58%-61% of women classified as high-/intermediate-risk (according to clinical guidelines) to low risk. Women reclassified to low risk showed a 5% rate of distant metastasis at 10 years.

CONCLUSION

The EPclin score is able to predict favorable prognosis in a majority of patients that clinical guidelines would assign to intermediate or high risk. EPclin may reduce the indications for chemotherapy in ER-positive postmenopausal women with a limited number of clinical risk factors.

Free asymmetric dimethylarginine (ADMA) is low in children and adolescents with classical phenylketonuria (PKU)

INTRODUCTION

Free asymmetric dimethylarginine (ADMA) is a competitive inhibitor of the nitric oxide synthases (NOS). Suppression of nitric oxide (NO) synthesis increases the risk of atherosclerosis. Nevertheless, in the condition of oxidative stress, NOS blockade by ADMA may exert protective effects. Protein metabolism is altered in patients with phenylketonuria (PKU) on dietary treatment and as shown recently, oxidative stress is high in PKU. Since free ADMA concentrations are determined by both protein metabolism and oxidative stress we hypothesized, that free ADMA levels may be elevated in PKU patients.

DESIGN

Sixteen patientswith PKU on dietary treatment (mean age 10.1 ± 5.2 yrs), and 91 healthy children (mean age 11.6 ± 3.7 yrs) participated in a cross sectional study.

RESULTS

ADMA, total homocysteine (tHcy) and blood glucose were lower and the L-arginine/ADMA ratio was higher in PKU patients compared to controls. No significant correlation was present between phenylalanine (Phe) concentrations, protein intake, and lipid profile, history of cardiovascular disease or ADMA.

DISCUSSION

In contrast to our hypothesis, ADMAwas lower and the L-arginine/ADMA ratio was higher in PKU patients. Therefore, in PKU patients, the regulating function of ADMA on NO synthesis is altered and may thus contribute to oxidative stress.

Expression of the carbohydrate tumour marker Sialyl Lewis A, Sialyl Lewis X, Lewis Y and Thomsen-Friedenreich antigen in normal squamous epithelium of the uterine cervix, cervical dysplasia and cervical cancer

The carbohydrate molecules Sialyl Lewis X (SLeX), Sialyl Lewis A (SLeA), Lewis Y (LeY) and Thomsen-Friedenreich antigen (TF) are known to mediate the adhesion between tumor cells and endothelium. They are used as serum markers in diagnosis and treatment in a broad spectrum of human carcinomas, but their expression profile and role in the development of cervical cancer remains unclear. The aim of this study was to investigate the expression of SLeX, SLeA, LeY and TF in normal cervical squamous epithelium, cervical dysplasia and cervical cancer. Slides of paraffin-embedded tissue were fixed and incubated with monoclonal antibodies against SLeX, SLeA, LeY and TF. Immunohistochemical staining was evaluated by using a semi-quantitative score (IRS Score). We found a significant difference of SLeA expression in invasive cervical cancer compared to normal epithelium (p=0.006) and all grades of dysplasia (p=0.002). The expression of SLeX in normal epithelium was less intense than in carcinoma in situ (p=0.036). Staining for LeY showed the weakest results of the investigated markers. Significant differences were found when normal epithelium was compared to CIN I (p=0.011), to CIN II (p=0.013) and to invasive cervical cancer (p=0.005). For TF, significant differences were found in normal epithelium compared to CIN I (p=0.011), CIN II (p=0.013) and compared to invasive cervical cancer (p=0.005). This is the first study on the expression of SLeA, SLeX, LeY and TF in normal cervical endothelium, cervical dysplasia, carcinoma in situ and invasive cervical cancer. Further studies and higher numbers are desirable.

High-resolution breast tomography at high energy: a feasibility study of phase contrast imaging on a whole breast

Previous studies on phase contrast imaging (PCI) mammography have demonstrated an enhancement of breast morphology and cancerous tissue visualization compared to conventional imaging. We show here the first results of the PCI analyser-based imaging (ABI) in computed tomography (CT) mode on whole and large (>12 cm) tumour-bearing breast tissues. We demonstrate in this work the capability of the technique of working at high x-ray energies and producing high-contrast images of large and complex specimens. One entire breast of an 80-year-old woman with invasive ductal cancer was imaged using ABI-CT with monochromatic 70 keV x-rays and an area detector of 92×92 µm² pixel size. Sagittal slices were reconstructed from the acquired data, and compared to corresponding histological sections. Comparison with conventional absorption-based CT was also performed. Five blinded radiologists quantitatively evaluated the visual aspects of the ABI-CT images with respect to sharpness, soft tissue contrast, tissue boundaries and the discrimination of different structures/tissues. ABI-CT excellently depicted the entire 3D architecture of the breast volume by providing high-resolution and high-contrast images of the normal and cancerous breast tissues. These results are an important step in the evolution of PCI-CT towards its clinical implementation.

Retinoid X receptor alpha (RXRα) and peroxisome proliferator-activated receptor gamma (PPARγ) expression in breast cancer: an immunohistochemical study

BACKGROUND/AIM

The role of retinoid X receptor alpha (RXRα) and peroxisome proliferator-activated receptor gamma (PPARγ) in breast cancer has been well studied in vitro. The aim of the study was to assess the presence of these molecules in human breast cancer specimens and correlate them with major clinicopathological features.

PATIENTS AND METHODS

Tissue sections from 82 breast cancer cases clustered according to histological grade, lymph node (LN) and hormone receptor (HR) status were assessed by immunohistochemistry for RXRα and PPARγ.

RESULTS

RXRα was found to be strongly and moderately expressed in 11 (14.10%) and 33 (42.31%) cases, respectively. PPARγ was found to be strongly and moderately expressed in 33 (41.25%) and 25 (31.25%) cases, respectively. Only RXRα expression was inversely correlated with histological grade. Surprisingly, significantly elevated PPARγ expression was found in cases with positive LN status. Survival analysis did not yield significant results.

CONCLUSION

Our data support the current thesis of RXRα being a potential target for feature molecular interventions.

OT2-03-05: Evaluation of the Prevalence and Prognostic Significance of VEGF165b in Breast Cancer Patients Compared to Healthy Women

Background: VEGF165b mRNA was first isolated in 2002 by RT-PCR out of renal cortex tissue which resulted in a shorter PCR product than predicted from previously identified isoforms. This isoform was subsequently identified and cloned in both primary epithelial cells as well as in stable immortalized podocyte cell lines. Because of the nature of this splice variant and its distal splicing of the 3'-untranslated region of the VEGF mRNA, most previously investigated expression studies will not have distinguished VEGF165b form other isoforms. This may explain some of the data that does not show clear relationships between VEGF expression and angiogenesis. Moreover recent studies showing that VEGF-neutralizing antibodies could be more effective by targeting the proangiogenic splice variants rather than a pan-VEGF strategy. There has been only limited in vitro data regarding the role of VEGF165b but no in vivo data regarding the level of expression of VEGF165b in breast cancer or its possible correlation with disease progression.

Trial design: This is a monocentric observational cohort study with the primary objective to estimate the prevalence of VEGF165b in breast cancer patients compared to healthy controls and correlate it with existing clinical data. There are two groups of patients included in this study; patients with newly diagnosed breast cancer and healthy volunteers.

Eligibility criteria: The eligibility criteria for the breast cancer group are newly diagnosed ductal, lobular or inflammatory breast cancer at stage I-IV, no prior treatment, above 18 years of age. The eligibility criteria for the healthy volunteers are healthy women with no history of cancer with no current medical therapies and above 18 years of age. Specific aims: The primary objective of this trial is to estimate the prevalence of VEGF165b in breast cancer patients and healthy volunteers. The secondary objective is the correlation of VEGF165b with clinical characteristics over time.

Statistical method: The statistical analysis being used in this study will be primarily descriptive with the calculation of mean and median and confidence intervals. The difference in distribution of the values will be examined in a one way variant analysis. We will also correlate results from different biospecimens and correlate the prevalence of variant presence or absence.

Material and methods: The samples will be analysed using a specific ELISA as well as immunohistochemistry. The accuracy and sensitivity of the available ELISA are of utmost importance in this setting. Bates et al have done previous work evaluating the ELISA used in this study and have shown that it underestimates the value for VEGF165b but that it is specific for VEGF165b. Since we will rather look at individual variation over the course of time, it will not have an effect regarding the expected results but it prohibits a direct comparison of the measured levels of VEGF165 to VEGF165b if they are not corrected for this lack in sensitivity.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-03-05.

Topoisomerase IIalpha expression rather than gene amplification predicts responsiveness of adjuvant anthracycline-based chemotherapy in women with primary breast cancer

INTRODUCTION

Adjuvant anthracycline-based chemotherapy (AbCTX) is a standard treatment for patients with primary breast cancer. Its main target is topoisomerase IIalpha (TopIIa), a nuclear protein which is important for DNA replication and mitosis. We propose that the overexpression of the TopIIa protein or amplification of the TopIIa gene may be useful in predicting increased responsiveness towards AbCTX.

METHODS

Tumor tissues of 118 patients who received adjuvant AbCTX were examined by immunohistochemistry (IHC) and fluorescence in situ hybridisation (FISH) for TopIIa and HER2. For IHC, the primary antibodies 485 (Dako) and NCL-TOPOIIA (Novocastra) were used. FISH analysis was performed with the SPEC HER2/CEP 17 Dual Color Probe (Zytovision) and LSI TOP 2A Spectrum Orange/CEP 17 Spectrum Green probe (Abbott). TopIIa IHC was evaluated by the immunoreactive score (IRS). FISH amplification was stated at an HER2-TopIIa/CEP 17 ratio > or = 2, deletion of TopIIa at a ratio <0.8.

RESULTS

The median age of the patient population was 50 years (range 23-77), 76 (64%) had tumors >2 cm in size, 98 (85%) were nodal positive, and 72 (66%) estrogen-receptor positive. Chemotherapy regimes consisted of epirubicin-cyclophosphamide (EC 40 pts), EC-CMF (18 pts), FAC/FEC (33 pts), anthracycline-taxane combinations (23 pts) and others (4 pts). After IHC, it was found that 19% of the tumors were positive for HER2 (3+) and the median IRS for TopIIa staining was 2 (49% positive); 28 (24%) tumors showed HER2 amplification, therefrom 20/22 (91%) within the HER2 3+ group. TopIIa gene was amplified in 17 cases (16%) and deletion was seen in 6 (5%) tumors. Of all cases with HER2 gene amplification, 14 (50%) cases of TopIIa co-amplification and one case of deletion were seen. Looking at histological parameters, TopIIa IHC correlated with nodal status (P = 0.018) and high grading (G3) (P = 0.047). After a median follow-up of 42 months (range 1-242), a significant prognostic factor for local recurrence was HER2 positivity (IHC P = 0.013 and FISH P = 0.023). Thirty-two patients developed metastasis (27%), which was correlated with HER2 FISH positivity (P = 0.024) and, as a trend, Top IIa IHC negativity (P = 0.094); 25 (21%) patients died from the disease. Negative prognostic parameters were the lack of estrogen-receptor expression (P = 0.008), lymphangiosis (P = 0.02), and TopIIa IHC negativity (P = 0.03).

CONCLUSION

In this cohort of patients, HER2 positivity indicated higher rates of local and distant recurrence. In contrast, TopIIa IHC positivity predicted lower risk of metastases and death, thus being a positive-predictive factor for the responsiveness to AbCTX. TopIIa gene amplification did not add predictive information. Therefore, we conclude that TopIIa protein expression might rather be the target of anthracyclines independent from gene copy number.