P5-09-02: Reducing Excess Biopsies: Improving Screening through Risk Stratification and New Thresholds for Intervention

Background BI-RADS Category 4 patients have a 2–95% risk for malignancy and are generally recommended for breast biopsy with little discrimination for risk level or distinction between risk of invasive or in situ disease. Our study sought to determine if higher thresholds for biopsy based on stratifying for risk and distinguishing between risk of invasive cancer and DCIS could reduce biopsy rates and increase cancer-to-biopsy yields without missing cancers urgent for resolution.

Methods 108 BI-RADS 4 cases with final outcomes data were evaluated from a prospective cohort of 215 consecutive patients seen at a same-day multidisciplinary breast clinic for women with mammograms categorized as BI-RADS 0, 4, or 5 in 2006–07. Final outcomes were determined from pathologic diagnosis or two-year follow-up. Risk estimates (RE) for DCIS and invasive cancer were collected prospectively and re-assessed by a radiologist blinded to outcomes and prior reading assessments. Cases were stratified according to the risk ranges of the BI-RADS 4 subcategories and risk of invasive or in situ disease. Biopsy rates, cancer-to-biopsy yields, and number of malignancies missed were calculated for various thresholds for intervention.

Results A ROC curve for invasive cancer risk for the radiologist demonstrated a 98.5% level of accuracy (95% confidence interval [CI]: 96.9%, 100%). 60 cases had some risk for invasive cancer and 48 had some risk for DCIS. There were 14 invasive cancer and 11 DCIS outcomes, 3 of which were high-grade. Pathologic assessment from biopsy or surgery was available for 100 patients. The outcomes of 8 cases were determined by benign two-year follow-up.

There are several strategies for intervention that improve biopsy yield and reduce biopsies for benign disease as shown in Table 1.

P4-02-10: The Relationship between Estrogen Receptor Gene Polymorphism and Mammographic Density in Postmenopausal Women

Background Assess the relation between the presence of PVUII and XBAI polymorphisms in the estrogen receptor alpha gene and mammographic density in postmenopausal women.

Methods For the present analysis, 189 postmenopausal women who had never used hormonal therapy and who did not have clinical or mammographic features were selected. Based on the ACR-BIRADSâ 2003 classification, the mammographic density was determined by three independent readers (two subjective ratings and one computerized - Adobe Photoshop â 7.0 software). Blood samples were available to extract DNA according to KIT GFX â protocol. PCR-RFLP (Polymerase Chain Reaction - Restriction Fragment Length Polymorphism) was then used to identify the polymorphisms.

Results There was a high degree of agreement among the three readers to determine the mammographic density (Kappa>0.75). Sixty women (32%) had dense breasts and 129 (68%) had non-dense breasts. The PVUII polymorphism was found in 132 (69.8%) of 189 women, while the XBAI was found in 135 (71.4%) of women. Parity (p=0.02) and body mass index (p<0.0001) were associated with mammographic density. It was observed that for the XBAI polymorphism, women with two mutated alleles were approximately 2.5 times more likely to be classified in dense breasts group (p=0.003) and the presence of both wild alleles was associated with fibroglandular tissue replacement by fat (p=0.02).

Conclusions There was no significant association of the PVUII polymorphism in the estrogen receptor alpha gene with mammographic density (p=0.34). However, the XBAI polymorphism was observed at a higher mutated homozygous frequency in women with dense breasts and there was an increased frequency of wild-type homozygous and heterozygous women with fat-replaced breasts (p=0.01).

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-02-10.

Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial

OBJECTIVE

The purpose of this study was to assess the safety and efficacy of the ClariVein(®) system that employs mechanochemical ablation of the great saphenous vein (GSV).

METHOD

Patients eligible for ablation of the GSV underwent micropuncture access with only local anaesthesia to insert a 4 or 5 Fr sheath. The ClariVein(®) catheter was placed through the sheath, the wire was extruded, and the distal tip of the wire positioned 2 cm from the saphenofemoral junction under ultrasound guidance. Catheter wire rotation was then activated for 2-3 seconds at approximately 3500 rpm. With the wire rotating, infusion of the sclerosant was started simultaneously with catheter pullback. The sclerosant used was 1.5% liquid sodium tetradecyl sulphate (Sotradecol(©), Bioniche Pharma Group, Geneva, Switzerland).

RESULTS

Thirty GSVs in 29 patients were treated. All patients have reached six-month follow-up; the average number of postoperative days is 260. No adverse events have been reported. The Primary Closure Rate is 96.7%.

CONCLUSION

Mechanochemical ablation appears to be safe and efficacious. The ClariVein(®) technique eliminates the need for tumescent anaesthesia. The great majority of incompetent GSVs can be treated with this technique.

Focal adhesion kinase protein regulates Wnt3a gene expression to control cell fate specification in the developing neural plate

FAK is linked to aggressive tumors, but its normal function is not clear. FAK knockdown early in Xenopus development anteriorizes the embryo via a loss of Wnt signaling. Wnt3a expression is FAK dependent in both embryos and human breast cancer cells, suggesting that a FAK–Wnt linkage is highly conserved.

Focal adhesion kinase (FAK) is a cytoplasmic tyrosine kinase protein localized to regions called focal adhesions, which are contact points between cells and the extracellular matrix. FAK protein acts as a scaffold to transfer adhesion-dependent and growth factor signals into the cell. Increased FAK expression is linked to aggressive metastatic and invasive tumors. However, little is known about its normal embryonic function. FAK protein knockdown during early Xenopus laevis development anteriorizes the embryo. Morphant embryos express increased levels of anterior neural markers, with reciprocally reduced posterior neural marker expression. Posterior neural plate folding and convergence-extension is also inhibited. This anteriorized phenotype resembles that of embryos knocked down zygotically for canonical Wnt signaling. FAK and Wnt3a genes are both expressed in the neural plate, and Wnt3a expression is FAK dependent. Ectopic Wnt expression rescues this FAK morphant anteriorized phenotype. Wnt3a thus acts downstream of FAK to balance anterior–posterior cell fate specification in the developing neural plate. Wnt3a gene expression is also FAK dependent in human breast cancer cells, suggesting that this FAK–Wnt linkage is highly conserved. This unique observation connects the FAK- and Wnt-signaling pathways, both of which act to promote cancer when aberrantly activated in mammalian cells.

Abstract P6-02-02: Evaluation of the Clinical Efficacy of Minimally Invasive Procedures for Breast Cancer Screening at a Teaching Hospital

Objective: To assess the clinical accuracy of diagnostic procedures for breast cancer at a teaching hospital using internal auditing tools and quality control measures.

Study Design: Retrospective assessment of 500 patients who underwent core needle biopsy (wide-bore needle biopsy - WBN) of palpable or non-palpable breast nodes and also were submitted to at least one cytologic examination [fine needle aspiration cytology (FNA) and/or imprint of a WBN specimen]. For statistical assessment, we utilized the auditing tool and quality control proposed by the National Health Service — Breast Screening Program (NHSBSP).

Results: For FNA, specificity full (SPEC), positive predictive value (PPV), inadequate rates and suspicious rates were satisfactory while absolute sensitivity (AS), complete sensitivity (CS), false-negatives (FNs) and false-positives (FPs) were unsatisfactory. For imprint, AS, CS, inadequate rate from cancers and suspicious rate were satisfactory, and the remaining indicators were unsatisfactory. WBN displayed the best performance with AS, CS, FN, suspicious rate, SPEC and PPV, showing satisfactory results and only one unsatisfactory result (FP).

Comparison of quality control measures of fine-needle aspiration (n=395), imprint (n=182) and core-needle biopsy (n=500) performed at the UNIFESP-EPM Breast Clinic from January 2002 to April 2007 with the

Min — minimuml; Unif — Unifesp-EPM; PPV — Positive predictive value, NA — not applicable

Conclusion: Based on an overall analysis, WBN displayed the highest clinical efficacy compared with FNA and imprint and demonstrated adequate safety for confirming the appropriate diagnosis and management of patients, ensuring the efficacy of the service.

Mesodermal Wnt signaling organizes the neural plate via Meis3

In vertebrates, canonical Wnt signaling controls posterior neural cell lineage specification. Although Wnt signaling to the neural plate is sufficient for posterior identity, the source and timing of this activity remain uncertain. Furthermore, crucial molecular targets of this activity have not been defined. Here, we identify the endogenous Wnt activity and its role in controlling an essential downstream transcription factor, Meis3. Wnt3a is expressed in a specialized mesodermal domain, the paraxial dorsolateral mesoderm, which signals to overlying neuroectoderm. Loss of zygotic Wnt3a in this region does not alter mesoderm cell fates, but blocks Meis3 expression in the neuroectoderm, triggering the loss of posterior neural fates. Ectopic Meis3 protein expression is sufficient to rescue this phenotype. Moreover, Wnt3a induction of the posterior nervous system requires functional Meis3 in the neural plate. Using ChIP and promoter analysis, we show that Meis3 is a direct target of Wnt/beta-catenin signaling. This suggests a new model for neural anteroposterior patterning, in which Wnt3a from the paraxial mesoderm induces posterior cell fates via direct activation of a crucial transcription factor in the overlying neural plate.

Prognostic Value of Lymphogenic Micrometastasis of Patients with Breast Carcinoma: A Multicenter Cohort Study

Introduction: Since the introduction of sentinel lymph node biopsy (SLNB) for staging breast cancer, lymphogenic micrometastases are commonly detected. The prognostic meaning of these small lymph node metastases and the consequences regarding the indication for adjuvant systemic treatment is under debate. Currently, robust data with a long time follow up are lacking.Method: Between January 2000 and December 2002 1411 patients with a cT1-2N0 breast carcinoma underwent surgery in seven hospitals in the Netherlands. Pathological examination of the sentinel node consisted of serial sectioning of SLN's and H&E and IHC staining. Based on the presence of lymph node metastases patients where divided into four groups: pN0 (n = 922), pN1micro (n = 103), pN1a (n = 285) and pN≥1b (n = 101). Median follow up was 77 months.Results: At the end of follow-up 184 (13.0%) patients had died. Breast cancer recurred in 244 (17.3%) patients, 165 of them having distant metastases (11.7%) patients. The 5- years overall survival was 93% for patients with pN0 disease, 94% for pN1micro, 88% for pN1a and 78% for pN≥1b (p < 0.001). The 5-years disease free survival was 87%, 90%, 85% and 72% (p < 0.001) respectively.Following adjustment for possible confounding characteristics and for adjuvant systemic treatment, overall survival was similar for pN0 en pN1micro patients and significantly worse for pN1a and pN≥1b (HR 1.18; 95% CI 0.58-2.39, HR 2.47; 95% CI 1.69-3.63, HR 4.36; 95% CI 2.70-7.04 respectively). Disease free survival was similar too in the pN0 and pN1micro group, and worse for pN1a and pN≥1b (HR 0.96; 95% CI 0.56-1.67 vs. HR 1.64; 95% CI 1.19-2.27, HR 2.95; CI 1.98-4.42). Distant metastases were more commonly observed in the pN1micro group than in the pN0 group (HR 1.22; 95% CI 0.60-2.49), but not significantly and far less than in the pN1a and pN≥1b group (HR 2.26; 95% CI 1.49-3.40, HR 3.49; 95% CI 2.12-5.77).Conclusion: After a relative long time of follow up disease free and overall survival for patients with micrometastasis in SLNs is comparable to patients without lymphogenic metastasis and more favourable than patients with macrometastasis. The presence of micrometastatic disease in the SLN is in itself not an indication for adjuvant systemic therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 307.

Information preferences of high literacy pregnant women regarding informed consent models for genetic carrier screening

OBJECTIVE

With the increasing carrier screening options being offered to pregnant women, it is critical to consider what information women want in an informed consent process, and how they make decisions regarding screening.

METHODS

We surveyed 201 pregnant women.

RESULTS

Subjects prefer "to have as much information as possible" (84%), and valued their physician's recommendations (82%) regarding screening. After reviewing two hypothetical scenarios, 71% of participants preferred more information about genetic carrier screening; however, some participants expressed concern that too much information can also lead to anxiety. When specifically asked about components of a potential informed consent process, the highest preferences were to include: the chance of having a child with the disorder (97%), the options for carriers (93%), the value and purpose of testing (91%), and the prognosis if a child has the disease (94%); preference for "symptoms" information differed based on scenario preference (p<0.001).

CONCLUSION

This study is the first to document variation in patients' views regarding the information desired as part of the informed consent process.

PRACTICE IMPLICATIONS

Providers should consider ways to ascertain their patients' preferred informational style, and how to provide information in the amount and style that patients find useful in making decisions.

Portal vein thrombosis associated with coronary artery bypass surgery

Portal vein thrombosis is a rare but well-known complication after abdominal surgery. To our knowledge, there have been no reports about this complication after cardiopulmonary bypass surgery. This can probably be explained by the variety of clinical pictures and difficulties in the establishment of a diagnosis of portal vein thrombosis. Among the possible trigger factors, bacteremia, that is usually caused by Bacteroides fragilis or by Escherichia coli, has been assessed. In this case, several blood culture specimens and fluid from abdominal paracentesis consistently grew coagulase-negative staphylococci which have been proved to be one of the most common pathogens in postoperative infection after cardiac surgery. The patient received clopidogrel before and after coronary artery bypass grafting. We speculate that in this clinical situation associated with coagulase-negative staphylococcal bacteremia, clopidogrel resistance may play an important role. The natural history of portal vein thrombosis in this case is complicated by massive fatal gastrointestinal bleeding from rupture of the esophageal varices. Emergency endoscopic therapy with esophageal variceal ligation, injection of a sclerosing solution and using of vasoconstrictive agents helped only in the first episode of bleeding. Portal vein thrombosis after coronary artery bypass grafting is a serious complication. The clinical picture of portal vein thrombosis may vary greatly and the presence of this condition should be suspected when faced with abdominal pain with gastrointestinal bleeding of unknown origin and sepsis.

Chromogranins A and B and secretogranin II: evolutionary and functional aspects

Chromogranins/secretogranins or granins are a class of acidic, secretory proteins that occur in endocrine, neuroendocrine, and neuronal cells. Granins are the precursors of several bioactive peptides and may be involved in secretory granule formation and neurotransmitter/hormone release. Characterization and analysis of chromogranin A (CgA), chromogranin B (CgB), and secretogranin II (SgII) in distant vertebrate species confirmed that CgA and CgB belong to related monophyletic groups, probably evolving from a common ancestral precursor, while SgII sequences constitute a distinct monophyletic group. In particular, selective sequences within these proteins, bounded by potential processing sites, have been remarkably conserved during evolution. Peptides named vasostatin, secretolytin and secretoneurin, which occur in these regions, have been shown to exert various biological activities. These conserved domains may also be involved in the formation of secretory granules in different vertebrates. Other peptides such as catestatin and pancreastatin may have appeared late during evolution. The function of granins as propeptide precursors and granulogenic factors is discussed in the light of recent data obtained in various model species and using knockout mice strains.

What do patients prefer: informed consent models for genetic carrier testing

The recent increased number of conditions for which patients can undergo genetic carrier testing raises the question of how best to obtain pre-test informed consent. Clinical approaches vary from a minimalist model to a model where patients are given detailed information about all conditions to be screened for. Few data exist as to patient preferences, or how information impacts decision-making. Eight high-literacy focus groups were conducted to assess the knowledge and preferences of pregnant patients and their male partners. Most groups indicated that some balance between details and brevity was optimal, recognizing that anxiety can occur when patients are provided with too much information and that the wide range of tests offered during pregnancy often led to confusion. Critical areas for the informed consent process included (1) details about the conditions and risk of being a carrier, (2) logistics of testing, (3) next steps if the test is positive, and (4) prognosis, options and resources if the child were to be affected with a disorder. It will be useful to develop model consent programs and prospectively assess their impact on informed consent and patient satisfaction, both when positive and negative results are received.

Xenopus laevis POU91 protein, an Oct3/4 homologue, regulates competence transitions from mesoderm to neural cell fates

Cellular competence is defined as a cell's ability to respond to signaling cues as a function of time. In Xenopus laevis, cellular responsiveness to fibroblast growth factor (FGF) changes during development. At blastula stages, FGF induces mesoderm, but at gastrula stages FGF regulates neuroectoderm formation. A Xenopus Oct3/4 homologue gene, XLPOU91, regulates mesoderm to neuroectoderm transitions. Ectopic XLPOU91 expression in Xenopus embryos inhibits FGF induction of Brachyury (Xbra), eliminating mesoderm, whereas neural induction is unaffected. XLPOU91 knockdown induces high levels of Xbra expression, with blastopore closure being delayed to later neurula stages. In morphant ectoderm explants, mesoderm responsiveness to FGF is extended from blastula to gastrula stages. The initial expression of mesoderm and endoderm markers is normal, but neural induction is abolished. Churchill (chch) and Sip1, two genes regulating neural competence, are not expressed in XLPOU91 morphant embryos. Ectopic Sip1 or chch expression rescues the morphant phenotype. Thus, XLPOU91 epistatically lies upstream of chch/Sip1 gene expression, regulating the competence transition that is critical for neural induction. In the absence of XLPOU91 activity, the cues driving proper embryonic cell fates are lost.

Aggregation of maternal pigment granules is induced by the cytosolic discoidin domain of theXenopus Del1 protein

Xenopus oocytes generate pigment granules (melanosomes) that predominantly localize to the animal hemisphere cortex. During embryonic development, these granules are located near the membranes of outer layer ectoderm cells. We report a novel phenotype found during an expression cloning screen in Xenopus laevis embryos. The phenotype is characterized by dissociation of pigment granules from the cell membrane to form large central aggregates. This phenomenon was induced by a truncated form of the Xenopus Del1 (XDel1) protein that contains only the C-terminal discoidin (D2) domain. This truncated form of XDel1 localized to membranes as shown by a chimeric enhanced green fluorescent protein construct. Although a similar localization occurred in immature oocytes, dissociation of pigment granules was limited to the oocyte vegetal hemisphere. The full-length XDel1 cDNA was cloned, and XDel1 mRNA expression was found to be ubiquitous and continuous from early oocyte to tail bud stages, with a transient enrichment in the cement gland. Ectopic expression of various deletion or full-length constructs or antisense morpholino oligonucleotides did not induce any significant developmental phenotypes.

The Meis3 protein and retinoid signaling interact to pattern the Xenopus hindbrain

In Xenopus embryos, proper hindbrain formation requires activities of both XMeis3 protein and retinoic acid (RA) signaling. In this study, we show that XMeis3 protein and RA signaling differentially interact to regulate hindbrain patterning. The knockdown of XMeis3 protein prevented RA-caudalizing activity from inducing hindbrain marker expression in both explants and embryos. In contrast, inhibition of RA signaling differentially modulated XMeis3 activity. Target genes that are jointly activated by either RA or XMeis3 activities could not be efficiently induced by XMeis3 when RA signaling was inhibited. However, transcription of an XMeis3 target gene that is not an RA target gene was hyper-induced in the absence of retinoid signaling. Target genes jointly induced by RA or XMeis3 protein were synergistically activated in the presence of both activities, while RA treatment inhibits the ability of XMeis3 to activate transcription of neural genes that are not RA targets. HoxD1, an RA direct-target gene was also identified as an XMeis3 direct-target gene. HoxD1 protein acts downstream of XMeis3 to induce hindbrain marker gene transcription. To pattern the hindbrain, RA requires functional XMeis3 protein activity. XMeis3 protein appears crucial for initial hindbrain induction, whereas RA signaling defines the spatial limits of hindbrain gene expression by modifying XMeis3 protein activity.

Dose response characteristics of polymethacrylic acid gel (PMAAG) for a polymerization-based dosimeter using NMR

The radiation-response characteristics of polymetharylic acid gel dosimeter prepared with different concentrations of monomer and cross-linker is described in these studies. The dosimeters were prepared under the hypoxic condition in a glove box and were then irradiated with gamma-rays produced by Co-60 radionuclide that was generated at 1.25MeV energy. The irradiation took place at different doses ranged from 0Gy to 19Gy. Due to the radiation activities, chain-reaction polymerisation processes had taken place in the formation of polymethacrylic acid (PMAA) gel, which cause the dose response mechanism increased in the NMR relaxation rates of protons. It has been observed that for higher concentration of monomer and cross-linker, the polymerization rate was increased.

Radiation and temperature effects on conductivity properties of PVA-KOH-PC composite

The aim of this work was to study radiation and the effects of temperature on conductivity properties of polyvinyl alcohol (PVA)-based potassium hydroxide (KOH) and propylene carbonate (PC), where the ionic conduction preferentially occurs in the amorphous phase by free radicals ions through gamma-irradiation. Alkaline composite polymer electrolyte (ACPE) consisting of PVA, KOH and PC of different concentration ratios were prepared by solvent-casting technique. The ACPE were irradiated with different doses from 5 kGy up to 200 kGy. The conductivity properties of the electrolyte films were measured at different frequencies in the range 20 Hz to 1 MHz using LCR meter. The results showed that the conductivity properties were dependent on the radiation dose, temperature and the concentration of the polymer blends.