Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

The effects of angiotensin receptor neprilysin inhibition by sacubitril/valsartan on adipose tissue transcriptome and protein expression in obese hypertensive patients

Increased activation of the renin-angiotensin system is involved in the onset and progression of cardiometabolic diseases, while natriuretic peptides (NP) may exert protective effects. We have recently demonstrated that sacubitril/valsartan (LCZ696), a first-in-class angiotensin receptor neprilysin inhibitor, which blocks the angiotensin II type-1 receptor and augments natriuretic peptide levels, improved peripheral insulin sensitivity in obese hypertensive patients. Here, we investigated the effects of sacubitril/valsartan (400 mg QD) treatment for 8 weeks on the abdominal subcutaneous adipose tissue (AT) phenotype compared to the metabolically neutral comparator amlodipine (10 mg QD) in 70 obese hypertensive patients. Abdominal subcutaneous AT biopsies were collected before and after intervention to determine the AT transcriptome and expression of proteins involved in lipolysis, NP signaling and mitochondrial oxidative metabolism. Both sacubitril/valsartan and amlodipine treatment did not significantly induce AT transcriptional changes in pathways related to lipolysis, NP signaling and oxidative metabolism. Furthermore, protein expression of adipose triglyceride lipase (ATGL) (P_time*group = 0.195), hormone-sensitive lipase (HSL) (P_time*group = 0.458), HSL-ser660 phosphorylation (P_time*group = 0.340), NP receptor-A (NPRA) (P_time*group = 0.829) and OXPHOS complexes (P_time*group = 0.964) remained unchanged. In conclusion, sacubitril/valsartan treatment for 8 weeks did not alter the abdominal subcutaneous AT transcriptome and expression of proteins involved in lipolysis, NP signaling and oxidative metabolism in obese hypertensive patients.

Abstract P1-07-09: Serum activin A and outcomes in HR+ /HER2- metastatic breast cancer patients treated with everolimus: Results from BOLERO-2

Background: Everolimus (EVE) plus exemestane (EXE) doubled progression-free survival (PFS) while maintaining quality of life versus EXE alone in postmenopausal women with hormone receptor positive (HR+), HER2-negative metastatic breast cancer (mBC) (BOLERO-2 phase 3; NCT00863655). Pretreatment serum activin A was previously reported as a prognostic factor in first-line hormone therapy (letrozole vs tamoxifen) (Novartis P025) and anti-HER2 mBC (lapatinib vs trastzmab) (CCTG MA.31) trials. Here we investigate the prognostic and predictive ability of activin A in BOLERO-2.

Methods: Activin A levels were determined on pretreatment serum samples using ELISA. Cox-proportional hazards model was used to assess the efficacy of EVE in the activin A low and high subgroups (median cut-point), and the prognostic effect of activin A on PFS and overall survival (OS).

Results: Baseline activin A levels were determined in 513 patients (71% of 725 BOLERO-2 patients randomized 2:1 to EVE+EXE or EXE). Predictive and prognostic signals are shown in the table below

Predictive and prognostic signalsPredictive/PrognosticEnd-pointAct-ivin ATreatmentNEventsMedian PFSHR (95% CI); p valuepredictivePFSHEXE93832.5 (1.5-2.8)-predictivePFSHEVE+EXE1631325.4 (4.1-6.8)0.46 (0.34 - 0.60); &lt;0.0001predictivePFSLEXE89774.2 (2.0 -5.4)-predictivePFSLEVE+EXE1681059.9 (8.1-12.5)0.38 (0.28 - 0.51); &lt;0.0001predictiveOSHEXE936820.1 (13.8-22.6)-predictiveOSHEVE+EXE16312917.7 (15.7-22.3)1.04 (0.78 - 1.40); 0.78predictiveOSLEXE8939NA (34.7-NA)-predictiveOSLEVE+EXE1687241.4 (36.4-NA)1.02 (0.69 - 1.50); 0.93prognosticPFSH 2562154.1 (2.9-4.2)-prognosticPFSL 2571826.9 (6.7-8.5)0.54 (0.45 - 0.66); &lt;0.0001prognosticOSH 25619718.0 (16.5-21.1)-prognosticOSL 25711142.3 (38.5-NA)0.34 (0.27 - 0.42); &lt;0.0001

.

In multivariate analysis (including sensitivity to prior hormone therapy and visceral disease), activin A remained a significant independent prognostic factor for PFS and OS [HR 0.57 (0.46-0.69) and 0.34 (0.27-0.43), respectively].

Conclusions: Higher serum activin A was strongly associated with shorter PFS and OS in HR+/HER2- mBC patients. Everolimus was efficacious regardless of serum activin A level. These results are similar to our previous studies in phase 3 trials of letrozole-tamoxifen (Novartis P025), and HER2-targeted therapy, lapatinib vs trastuzmab (CCTG MA.31): pretreatment serum activin A was prognostic for outcome, but was not a predictive factor for treatment arm selection.

Citation Format: Ali SM, Chen D, Ali A, Krecko L, Leitzel K, Vasekar M, Nagabhairu V, Marks E, Polimera H, Richardson A, May M, He W, Patel P, Lavin M, Hofsess S, Sweetman R, Hortobagyi G, Baselga J, Lipton A. Serum activin A and outcomes in HR+ /HER2- metastatic breast cancer patients treated with everolimus: Results from BOLERO-2 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-09.

Is it Possible to Provide a Prognosis after Radical Prostatectomy for Prostate Cancer by Means of a Psa Regression Model?

Background

For over 15 years, studies have been done to evaluate the elimination kinetics of the prostate-specific antigen (PSA) after radical prostatectomy. Even though evaluation of PSA regression in the two-compartment model has become established, no clear data are currently available as to whether a statement can be made with regard to tumor prognosis from a computation of the PSA half-life (PSA-HL). This study focuses on the determination of the PSA-HL in the two-compartment model and on its correlation with the biochemical recurrence-free survival. In addition, a computer program is being developed to simplify the determination of PSA-HL.

Material and methods

Seventy-seven prospective patients were examined who subsequently had a radical prostatectomy at our facility without neoadjuvant or adjuvant hormone deprivation. In addition to preoperative measurement of the PSA value (d0), PSA determinations were carried out postoperatively on days 5, 10 and 60, and at four-monthly intervals thereafter (mean follow-up: 16 months). By means of the computer program developed for this purpose, CTK. TumW, the PSA half-lives for the first (d0–d5, PSA-HL1) and second (d5–d10, PSA-HL2) compartments were subsequently determined and their effect on biochemical recurrence-free survival was assessed.

Results

PSA-HL1 and PSA-HL2 were 1.89 (± 0.03) and 3.39 (± 0.14) days, respectively. Whilst PSA-HL1 did not permit any prognostic statement, the median PSA-HL in the second compartment between patients with and without disease progression differed significantly (4.44 versus 3.12 days; p<0.001). Discrimination analysis produced a cutoff of 3.8 days for the second compartment; patients with a PSA-HL2 ≥3.8 days had a significantly worse biochemical recurrence-free survival after 18 months than the other patients (27% versus 93%; p<0.001).

Conclusion

The PSA regression kinetics after radical prostatectomy follows a two-compartment model in which the prognostic value of the PSA-HL1 is limited. When a cutoff of 3.8 days is used, evaluation of the PSA-HL in compartment 2 (d5–10) appears to permit a prognostic statement. Due to the limited postsurgical follow-up, the disease process was only assessed as biochemical recurrence-free survival, and a longer follow-up will be necessary to generate data on progression-free survival.

Isoform specificity of progesterone receptor antibodies

Progesterone receptors (PR) are prognostic and predictive biomarkers in hormone‐dependent cancers. Two main PR isoforms have been described, PRB and PRA, that differ only in that PRB has 164 extra N‐terminal amino acids. It has been reported that several antibodies empirically exclusively recognize PRA in formalin‐fixed paraffin‐embedded (FFPE) tissues. To confirm these findings, we used human breast cancer xenograft models, T47D‐YA and ‐YB cells expressing PRA or PRB, respectively, MDA‐MB‐231 cells modified to synthesize PRB, and MDA‐MB‐231/iPRAB cells which can bi‐inducibly express either PRA or PRB. Cells were injected into immunocompromised mice to generate tumours exclusively expressing PRA or PRB. PR isoform expression was verified using immunoblots. FFPE samples from the same tumours were studied by immunohistochemistry using H‐190, clone 636, clone 16, and Ab‐6 anti‐PR antibodies, the latter exclusively recognizing PRB. Except for Ab‐6, all antibodies displayed a similar staining pattern. Our results indicate that clones 16, 636, and the H‐190 antibody recognize both PR isoforms. They point to the need for more stringency in evaluating the true specificity of purported PRA‐specific antibodies as the PRA/PRB ratio may have prognostic and predictive value in breast cancer.

Characterization of Pontibacter altruii, sp. nov., isolated from a human blood culture

The genus Pontibacter is a recent addition to the family Cytophagaceae, phylum Bacteroidetes. Previous reports of its cultivation and molecular detection are from a variety of environmental sources, including marine and desert habitats. We report the first description of a Pontibacter sp., which was initially identified as Elizabethkingia meningoseptica, isolated from a human clinical specimen. On the basis of 16S rRNA gene sequence, unique mass spectral profile and phenotypic characterization, this isolate represents a novel species within the genus Pontibacter that has been named Pontibacter altruii, sp. nov., strain Grand Forks.

[What is the perception of the 10-point plan of the German Federal Ministry of Health against multidrug-resistant pathogens and measures of antibiotic stewardship? : An interdisciplinary analysis among German clinicians and development of a decision tool for urologists]

BACKGROUND

Due to increasing antibiotic resistances, relevant treatment problems are currently emerging in clinical practice. In March 2015, the German Federal Ministry of Health (BMG) published a 10-point plan designed to combat this development. Furthermore, the first German guideline on antibiotic stewardship (ABS) was implemented in 2013 and instructs physicians of different specialties about several treatment considerations. Evidence is scarce on how such concepts (10-point plan/BMG, ABS) are perceived among clinicians.

MATERIALS AND METHODS

Within the MR2 study (Multiinstitutional Reconnaissance of practice with MultiResistant bacteria - a survey focusing on German hospitals), a questionnaire including 4 + 35 items was sent to 18 German hospitals between August and October 2015, surveying internists, gynecologists, general surgeons, and urologists. Using multivariate logistic regression models (MLRM), the impact of medical specialty and further criteria on the endpoints (1) awareness of the 10-point plan/BMG and (2) knowledge of ABS measures were assessed. Fulfillment of endpoints was predefined when average or full knowledge was reported (reference: poor to no knowledge).

RESULTS

Overall response rate was 43% (456/1061) for fully evaluable questionnaires. Only 63.0 and 53.6% of urologists and nonurologists (internists, gynecologists, and general surgeons), respectively, attended training courses regarding multidrug-resistance or antibiotic prescribing in the 12 months prior to the study (P = 0.045). The endpoints average and full knowledge regarding 10-point plan/BMG and ABS measures were fulfilled in only 31.4 and 32.8%, respectively. In MLRM, clinicians with at least one previous training course (reference: no training course) were 2.5- and 3.8-fold more likely to meet respective endpoint criteria (all P < 0.001). Medical specialty (urologists vs. nonurologists) did not significantly impact the endpoints in both MLRM.

CONCLUSIONS

The 10-point plan/BMG and ABS programs should be implemented into clinical practice, but awareness and knowledge of both is insufficient. Thus, it stands to reason that the actual realization of such measures is inadequate and continuous training towards rational prescription of antibiotics is necessary, regardless of medical specialty.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]

BACKGROUND

Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available.

OBJECTIVES

Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference.

MATERIALS AND METHODS

Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks.

RESULTS

For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators.

CONCLUSIONS

The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

Progesterone Receptor Isoform Ratio: A Breast Cancer Prognostic and Predictive Factor for Antiprogestin Responsiveness

Background

Compelling evidence shows that progestins regulate breast cancer growth. Using preclinical models, we demonstrated that antiprogestins are inhibitory when the level of progesterone receptor isoform A (PR-A) is higher than that of isoform B (PR-B) and that they might stimulate growth when PR-B is predominant. The aims of this study were to investigate ex vivo responses to mifepristone (MFP) in breast carcinomas with different PR isoform ratios and to examine their clinical and molecular characteristics.

Methods

We performed human breast cancer tissue culture assays (n = 36) to evaluate the effect of MFP on cell proliferation. PR isoform expression was determined by immunoblotting (n = 282). Tumors were categorized as PRA-H (PR-A/PR-B ≥ 1.2) or PRB-H (PR-A/PR-B ≤ 0.83). RNA was extracted for Ribo-Zero-Seq sequencing to evaluate differentially expressed genes. Subtypes and risk scores were predicted using the PAM50 gene set, the data analyzed using The Cancer Genome Atlas RNA-seq gene analysis and other publicly available gene expression data. Tissue microarrays were performed using paraffin-embedded tissues (PRA-H n = 53, PRB-H n = 24), and protein expression analyzed by immunohistochemistry. All statistical tests were two-sided.

Results

One hundred sixteen out of 222 (52.3%) PR+ tumors were PRA-H, and 64 (28.8%) PRB-H. Cell proliferation was inhibited by MFP in 19 of 19 tissue cultures from PRA-H tumors. A total of 139 transcripts related to proliferative pathways were differentially expressed in nine PRA-H and seven PRB-H tumors. PRB-H and PRA-H tumors were either luminal B or A phenotypes, respectively ( P = .03). PRB-H cases were associated with shorter relapse-free survival (hazard ratio [HR] = 2.70, 95% confidence interval [CI] = 1.71 to 6.20, P = .02) and distant metastasis-free survival (HR = 4.17, 95% CI = 2.18 to 7.97, P <  .001). PRB-H tumors showed increased tumor size ( P <  .001), Ki-67 levels ( P <  .001), human epidermal growth factor receptor 2 expression ( P =  .04), high grades ( P =  .03), and decreased total PR ( P =  .004) compared with PRA-H tumors. MUC-2 ( P <  .001) and KRT6A ( P =  .02) were also overexpressed in PRB-H tumors.

Conclusion

The PRA/PRB ratio is a prognostic and predictive factor for antiprogestin responsiveness in breast cancer.

AKT1 and AKT2 isoforms play distinct roles during breast cancer progression through the regulation of specific downstream proteins

The purpose of this study was to elucidate the mechanisms associated with the specific effects of AKT1 and AKT2 isoforms in breast cancer progression. We modulated the abundance of specific AKT isoforms in IBH-6 and T47D human breast cancer cell lines and showed that AKT1 promoted cell proliferation, through S6 and cyclin D1 upregulation, but it inhibited cell migration and invasion through β1-integrin and focal adhesion kinase (FAK) downregulation. In contrast, AKT2 promoted cell migration and invasion through F-actin and vimentin induction. Thus, while overexpression of AKT1 promoted local tumor growth, downregulation of AKT1 or overexpression of AKT2 promoted peritumoral invasion and lung metastasis. Furthermore, we evaluated The Cancer Genome Atlas (TCGA) dataset for invasive breast carcinomas and found that increased AKT2 but not AKT1 mRNA levels correlated with a worse clinical outcome. We conclude that AKT isoforms play specific roles in different steps of breast cancer progression, with AKT1 involved in the local tumor growth and AKT2 involved in the distant tumor dissemination, having AKT2 a poorer prognostic value and consequently being a worthwhile target for therapy.

A Novel Effect of β-Adrenergic Receptor on Mammary Branching Morphogenesis and its Possible Implications in Breast Cancer

Understanding the mechanisms that govern normal mammary gland development is crucial to the comprehension of breast cancer etiology. β-adrenergic receptors (β-AR) are targets of endogenous catecholamines such as epinephrine that have gained importance in the context of cancer biology. Differences in β₂-AR expression levels may be responsible for the effects of epinephrine on tumor vs non-tumorigenic breast cell lines, the latter expressing higher levels of β₂-AR. To study regulation of the breast cell phenotype by β₂-AR, we over-expressed β₂-AR in MCF-7 breast cancer cells and knocked-down the receptor in non-tumorigenic MCF-10A breast cells. In MCF-10A cells having knocked-down β₂-AR, epinephrine increased cell proliferation and migration, similar to the response by tumor cells. In contrast, in MCF-7 cells overexpressing the β₂-AR, epinephrine decreased cell proliferation and migration and increased adhesion, mimicking the response of the non-tumorigenic MCF-10A cells, thus underscoring that β₂-AR expression level is a key player in cell behavior. β-adrenergic stimulation with isoproterenol induced differentiation of breast cells growing in 3-dimension cell culture, and also the branching of murine mammary epithelium in vivo. Branching induced by isoproterenol was abolished in fulvestrant or tamoxifen-treated mice, demonstrating that the effect of β-adrenergic stimulation on branching is dependent on the estrogen receptor (ER). An ER-independent effect of isoproterenol on lumen architecture was nonetheless found. Isoproterenol significantly increased the expression of ERα, Ephrine-B1 and fibroblast growth factors in the mammary glands of mice, and in MCF-10A cells. In a poorly differentiated murine ductal carcinoma, isoproterenol also decreased tumor growth and induced tumor differentiation. This study highlights that catecholamines, through β-AR activation, seem to be involved in mammary gland development, inducing mature duct formation. Additionally, this differentiating effect could be resourceful in a breast tumor context.

Abstract P6-11-13: Phase Ib study evaluating the safety and clinical activity of lumretuzumab combined with pertuzumab and paclitaxel in HER2-low metastatic breast cancer

Background: Inhibition of HER2 and HER3 heterodimerisation is a novel treatment concept in HER2-”low” expressing breast cancer (BC). Lumretuzumab, a glycoengineered monoclonal anti-HER3 antibody, in combination with pertuzumab has demonstrated synergistic anti-tumor activity in preclinical HER2–low expressing preclinical BC models.

Methods: This open-label, multicenter phase I study selectively enrolled metastatic BC patients (pts) expressing HER3 protein and low levels of HER2 (defined as IHC 1+ and 2+ and ISH-negative) in a formalin-fixed paraffin-embedded pretreatment tumor biopsy sample. Eligible pts were treated with a combination of paclitaxel (PA) qw plus lumretuzumab (L) and pertuzumab (P) q3w in three dose cohorts. The safety, antitumor activity and tumor biomarkers including protein expression (IHC, MS) and mutational data (NGS) in association with clinical activity were evaluated.

Results: Overall, 35 pts were included in this study. The median age was 60 (range: 33 to 77) years. The median number of prior treatments for metastatic disease ranged from 0 to 5 with 23 pts (65.7%) without prior chemotherapy for metastatic disease. Cohort 1 was treated with PA at 80 mg/m2, L at 1000 mg and P at 840 mg for Cycle 1 followed by 420 mg for the following cycles. This cohort was stopped after two pts both experienced grade 3 diarrhea within the first treatment cycle which was considered a dose-limiting toxicity (DLT). For Cohort 2 the dose of L was reduced to 500 mg based on PK modelling and simulation data. No DLTs were seen for the first 6 pts. A total of 20 pts were recruited with an objective response rate (ORR) and disease control rate (DCR) of 30% and 75%, respectively, and 56% and 78%, respectively, for 1st-line pts (n=9) in this cohort. Diarrhea (≥G3) and hypokalemia (≥G3) occurred in 50% and 55% of pts, respectively, and all pts experienced chronic diarrhea throughout the course of treatment. For Cohort 3 the dose of L was maintained at 500 mg, PA at 80 mg/m2, and P was administered at 420 mg at all cycles. In addition, a prophylactic loperamide regimen was introduced. Altogether, 13 pts - all 1st-line for metastatic disease - were treated. No DLTs were seen for the first 6 pts. Diarrhea (≥G3) and hypokalemia (≥G3) were reduced to 31% and 15%, respectively, but chronic diarrhea was still observed throughout the treatment in all pts. The ORR and DCR were 31% and 77%, respectively. Preliminary mechanistic safety experiments revealed HER2/HER3-dependent chloride channels in the intestine as likely cause of diarrhea. Biomarker data will be presented along with updated clinical and safety data.

Conclusions: The combination of L, P and PA was associated with high rates of persistent diarrhea. Dose modifications and prophylactic anti-diarrheal medication led to significantly reduced diarrhea intensity but did not change the incidence and persistence of diarrhea overall. Despite encouraging clinical activity especially in 1st line pts, the therapeutic window of this combination is too low to warrant further clinical development.

Citation Format: Schneeweiss A, Park-Simon T-W, Albanell J, Lassen U, Cortes J, Dieras V, May M, Schindler C, Marmé F, Cejalvo JM, Martinez-Garcia M, Gonzalez I, Lopez-Martin J, Welt A, Joly F, Michielin F, Jacob W, Adessi C, Moisan A, Meneses-Lorente G, James I, Ceppi M, Hasmann M, Weisser M, Cervantes A. Phase Ib study evaluating the safety and clinical activity of lumretuzumab combined with pertuzumab and paclitaxel in HER2-low metastatic 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 P6-11-13.