[Results of a Questionnaire-Based Study on Guideline Adherence Regarding Adjuvant Treatment Recommendations for Patients with Non-Muscle-Invasive Bladder Cancer: Just a Disturbing Sidelight?]

BACKGROUND

The EAU guidelines on non-muscle-invasive bladder cancer (NMIBC) provide for risk stratification in low, intermediate and high risk based on infiltration depth, grading, concomitant carcinoma in situ, recurrence status, focality and tumour size. The aim of this study was to evaluate guideline adherence regarding risk stratification and risk-adapted treatment recommendations in NMIBC.

MATERIAL AND METHODS

An email-based survey distributed over the urological professional associations of Berlin, Brandenburg, Bremen, Hamburg, Mecklenburg-Western-Pomerania, Lower Saxony and Schleswig-Holstein assessed field of activity (doctor's office vs. clinic) and the presence of the additional qualification "Medical Tumour Therapy" (aqMtt). Also it inquired about the tools used for risk stratification in NMIBC. Finally, 3 scenarios were given, 2 of them corresponding to high-risk NMIBC and one corresponding to intermediate-risk NMIBC. Respondents were asked to provide a treatment recommendation. The results were presented comparatively for field of activity (doctor's office vs. clinic) and presence of aqMtt.

RESULTS

74 responses were received (response rate of 12.3%). 57 (77.0%) of respondents had aqMtt. 52 (70.3%) worked in doctor's offices or medical care centres, 12 (16.2%) in a urology clinic, and for 10 (13.5%) respondents this information was lacking. The most frequently used tool for risk stratification was the EAU guideline. Accordingly, treatment recommendations for the three scenarios were considered to be correct if according to EAU guideline. In high-risk NMIBC, an average 29.3% (19.3-37.5%) of adequate treatment recommendations were made depending on the comparison group. An average of 69.8% (62.5-77.2%) and 0.9% (0.0-3.9%) treatment recommendations would lead to under- or overtreatment, respectively. The corresponding values for intermediate-risk NMIBC were 56.8% (52.6-62.5%) for adequate treatment, 43.2% (37.5-47.4%) for undertreatment and 0.0% for overtreatment. Field of activity and the presence of aqMtt had no significant impact on the accuracy of treatment recommendations.

CONCLUSION

The results of our survey provide strong evidence of poor guideline adherence with a consecutive risk for undertreatment of patients with NMIBC. This requires joint efforts of all those involved in the treatment of NMIBC to improve quality of care.

Abstract B34: A novel role for β-adrenergic receptor in mammary branching morphogenesis and its implication in breast cancer

The mammary gland develops from embryogenesis to infancy-puberty and adulthood, by the input of circulating hormones. At birth the gland is composed of a rudimentary ductal system that grows allometrically until puberty (4-weeks in mice). Later on, estrogens, growth hormone and insulin like growth factor induce expansive proliferation. Normal breast has three types of lobules, type 1, 2 and 3. Full term pregnancy and lactation results in the development of lobule type 3 into type 4, preparing the gland for lactation. This transformation is known to inhibit carcinogenic initiation through the induction of differentiation.

β2-adrenergic receptors (β2-AR) have been well characterized in several human breast cell lines (normal and tumor) and in tissue samples. Recently, we have demonstrated that β2-AR expression and stimulation are associated with a benign breast tumor cell phenotype, reducing proliferation and cell migration, and increasing adhesion, suggesting that this receptor might be an important factor during tumor progression. In order to understand the implications of β2-AR on breast development and cancer, we evaluated β-activation in experimental models of normal and tumor breast, using cell lines, cultures 3D and in vivo approaches.

Non tumor breast cell line MCF-10A cultured during 15 days on matrigel, formed gland-like organoids. Tubular structures mimicking mammary ducts were recognized, with type 1 and 2 lobules. No sign of lumen was observed. When treated with the β-agonist Isoproterenol (1 μM ISO) MCF-10A cells showed an increase in type 2 and 3 lobules (p<0.001) and the presence of lumen was observed. Furthermore, breast cancer cells MCF-7 growing in 3D, formed unorganized espheroid structures. When treated with ISO these structures acquire a polarized phenotype and some of them develop lumen.

Later, Balb/c female virgin mice, weaning and 2 months old were treated daily with ISO 1 mg/Kg during 15 days. Control groups received saline solution. Mice were sacrificed and the 4th mammary glands were removed for Whole Mount and hematoxylin and eosin staining.

Interestingly, ISO induced a statistically significant difference in mammary gland branching in weaning (150±32 vs 57±21 branches/field in controls, p<0.05) as well as in puberal mice (196±16 vs 94±14, p<0.01). It is well established that branching is controlled by progesterone receptor (PR), estrogen receptor alpha (ERα), FGF2, FGF10 and FGFR2, hence we studied their involvement in β-AR effect. First, ISO action was assessed on PR knockout mice in which branches were also significantly increased (p<0.05). After that, we addressed ER related signaling comparing ovariectomized (OVX) or ER depleted (by fulvestrant administration) mice treated or not with ISO. In both cases, despite the administration of ISO, branching was not induced. These results suggest that estrogen receptor and its classical ligand, estrogen, are required for ISO-induced branching. In addition, ISO induced a significant increase of FGF2, FGF10 and FGFR2 expression in both in vitro treated cells and in ISO treated mammary glands (p<0.05).

Finally, we tested ISO in a mouse model of mammary ductal carcinoma. Surprisingly, tumors exhibited newly rough lumens and changes in cell polarity towards them, reinforcing the differentiating role of ISO also in a pathological context.

In conclusion, β-AR stimulation seems to be involved in normal mammary development, leading to a terminal stage phenotype. In agreement with this, the analysis of a publicly available MicroArray dataset (GSE8191) showed an increase in β-AR expression levels during lactation. This study highlights a possible physiological role of β-AR in the development of mammary gland. Understanding the function of β-AR in normal development is crucial to elucidate its role in breast cancer and its possible use as a therapeutic target.

Citation Format: Lucía Gargiulo, María May, Ezequiel Mariano Rivero, Lydon John, Caroline Lamb, Claudia Lanari, Isabel Alicia Luthy, Ariana Bruzzone. A novel role for β-adrenergic receptor in mammary branching morphogenesis and its implication in breast cancer. [abstract]. In: Proceedings of the AACR Special Conference: Developmental Biology and Cancer; Nov 30-Dec 3, 2015; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(4_Suppl):Abstract nr B34.

Abstract P4-09-13: Breast cancer recurrence risk: A role for the progesterone receptor isoforms

Progesterone receptor (PR) is currently used as a surrogate marker for functional estrogen receptor activity in breast cancer. Two PR isoforms have been described, PRB and PRA. PRA (94 kDa) is a truncated protein that lacks the first 164 amino acids of the NH2 terminal of PRB (115 kDa), making difficult the development of antibodies that discriminate PRA from PRB by standard immunohistochemistry (IHC). There are few studies describing the expression of PR isoforms in breast cancers. While there is a general consensus that PRA is the prevailing isoform expressed in breast cancer tissues as compared with normal mammary gland, there is controversial data regarding the association between their deregulated expression and endocrine response or aggressiveness. We are currently studying the expression of the PR isoform ratio in breast cancer samples obtained during surgical resection in order to test their antiprogestin responsiveness in tissue cultures. The study has been approved by the IRB (2012-028). Selected samples were studied by RNAseq and the data was used to analyze the PAM50 genes to predict risk of recurrence, and interestingly, almost all the genes related to proliferation were up-regulated in samples categorized as having higher levels of PRB than PRA, being also these patients those with a high risk of recurrence (May and Rojas et al., ASCO Annual Meeting, poster#11016, 2015). These observations are in agreement with data obtained in hormone resistant breast cancer xenografts with higher levels of PRB than PRA (Wargon and Riggio et al, International Journal of Cancer: 2680, 2015). The aim of this study is to evaluate a possible correlation between the PR isoform ratio, proliferation as evaluated by Ki67 or HER2 expression, and clinical outcome in selected breast cancer samples. Ki67 was evaluated by IHC using standard protocols in 80 PR+ samples. The PRA/PRB ratio was also evaluated in nuclear extracts, performed from frozen tissue, from the same patients, by Western Blot. A negative correlation was observed between the Ki67 score and the log2 value of the PRA/PRB ratio (Spearman R:-0.3418; p< 0.0029). Samples were considered PRA+ if PRA/PRB ≥ 1.2 and PRB+, if PRA/PRB ≤ 0.83. Seven out of 62 PRA+ (11.29%), and 7 out of 35 (20%) of PRB+ samples were HER2+. The differences between both groups, although not significant, correlate directly with the Ki67 evaluation. The results of this ongoing project lend support to the hypothesis that the ratio of PRA/PRB is associated with prognosis and highlight the role of PR as key players regulating breast cancer growth.

Citation Format: Gass HD, May M, Rojas P, Abba M, Sequeira G, Martinez Vazquez P, Gonzalez PL, Elía A, Alvarez MM, Molinolo A, Lanari CL. Breast cancer recurrence risk: A role for the progesterone receptor isoforms. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-13.

Does an Early and Aggressive Combined Wrapping and Dangling Procedure Affect the Clinical Outcome of Lower Extremity Free Flaps?-A Randomized Controlled Prospective Study Using Microdialysis Monitoring

Background The ideal starting point for flap training (FT) with the combined wrapping and dangling procedure is still a question of debate. Most units follow their own established protocols and currently evidence of flap compromise due to FT is still lacking. The aim of this study was to prove if an early and "aggressive" wrapping and dangling protocol could lead to metabolic changes, measured by microdialysis, indicating ischemia resulting in compromised flap perfusion. Methods Between 2010 and 2014, 49 patients with microvascular free flap reconstruction of the lower limb were included in this study. Patients were randomized into two groups. Group I started FT on the 7th postoperative day, and group II started on day 3. FT consisted of a combined wrapping and dangling procedure doubling its duration daily and ending at day 5. Flaps were monitored clinically and by microdialysis for ischemia-induced changes and metabolic parameters in the flap tissue in respect to different starting points of FT. Results All 49 patients in both groups were able to complete the postoperative FT without complications. Noninferiority of the early group could be proven and microdialysis results showed no differences between both groups. Conclusion We could prove by microdialysis that an early start of FT does not lead to compromised flap perfusion. Moreover, an early start of FT can lead to a reduced length of hospital stay. Furthermore, a reduced risk for deep vein thrombosis, pulmonary embolism, and pneumonia due to earlier mobilization might be an appreciated side effect.

Nuclear staining of fgfr-2/stat-5 and runx-2 in mucinous breast cancer

Mucinous carcinoma (MBC) is a rare subtype of breast cancer characterized by the production of variable amounts of mucin, with a prognosis better than that of non-mucinous carcinomas (NMBC). The aim of this project was to evaluate the expression of STAT-5, RUNX-2, and FGFR-2 in a cohort of MBC and compare it with that of NMBC using standard immunohistochemistry. STAT-5 and RUNX-2 are two transcription factors with cytoplasmic and/or nuclear localization that have been related to FGFR-2, a tyrosine kinase growth factor receptor that can interact with STAT-5 and with PR in the nuclei of breast cancer cells. Membranous, cytoplasmic, and nuclear staining were evaluated and expressed as the percentage of stained cells (0-100%) multiplied by the staining intensity (0-3), thus obtaining an index ranging from 0 to 300. Nuclear and/or cytoplasmic immunoreactivity of the three proteins were detected in a high number of NMBC. Nuclear FGFR-2 staining correlated with nuclear STAT-5 (p<0.05) and nuclear RUNX-2 (p<0.01) in both tumor types; however MBC had a significant higher expression of nuclear FGFR-2 (p<0.01) and RUNX-2 (p<0.05) than that of NMBC, and displayed positive immunoreactivity of the 3 proteins in 70.8% of the cases. These results suggest that these proteins may have a role in the progression of the mucinous phenotype, in which nuclear STAT-5 may inhibit RUNX-2 prometastatic effect.

[Rates of prostate-specific antigen testing for early detection of prostate cancer: a first comparison of German results with current international data]

OBJECTIVE

Measurement of prostate-specific antigen (PSA) is not only used as a screening instrument by urologists, but also by general practitioners and internal specialists (GP-IS). Until now, there are neither data on the approach of German GP-IS in practicing this nor have data been classified in the context of available international literature on this topic.

MATERIALS AND METHODS

Between May and December 2012, a questionnaire containing 16 items was sent to 600 GP-IS in Brandenburg and Berlin. The response rate was 65% (392/600). Six indicator questions (IQ1-6) were selected and results were set in the context of available international data. The quality of present studies was evaluated by the Harden criteria.

RESULTS

Of the 392 responding physicians, 317 (81%) declared that they would use PSA testing for early detection of PCA (IQ1) and, thus, formed the study group. Of these GP-IS, 38% consider an age between 41 and 50 years as suitable for testing begin (IQ2), while 53% and 14% of the GP-IS perform early detection until the age of 80 and 90 years, respectively (IQ3). A rigid PSA cut-off of 4 ng/ml is considered to be reasonable by 47% of the involved GP-IS, whereas 16% prefer an age-adjusted PSA cut-off (IQ4). Patients with pathological PSA levels were immediately referred to a board-certified urologist by 69% of the GP-IS. On the other hand, 10% first would independently control elevated PSA levels themselves after 3-12 months (IQ5). Furthermore, 14% of the interviewed physicians consider a decrease of PCA-specific mortality by PSA screening as being proven (IQ6). Knowledge regarding PCA diagnostics is mainly based on continuous medical education for GP-IS (33%), personal contact with urologists (6%), and guideline studies (4%). While 53% indicated more than one education source, 4% did not obtain any PCA-specific training. The results provided by this questionnaire evaluating response of German GP-IS to six selected indicator questions fit well into the international context; however, further studies with sufficient methodical quality are required.

CONCLUSIONS

Despite current findings and controversial recommendations of the two large PCA screening studies on this issue, German GP-IS still frequently use PCA screening by PSA measurement. Primary strategies of early detection as well as follow-up after assessment of pathologically elevated PSA levels poorly follow international recommendations. Thus, an intensification of specific education is justified.

Progestin and antiprogestin responsiveness in breast cancer is driven by the PRA/PRB ratio via AIB1 or SMRT recruitment to the CCND1 and MYC promoters

There is emerging interest in understanding the role of progesterone receptors (PRs) in breast cancer. The aim of this study was to investigate the proliferative effect of progestins and antiprogestins depending on the relative expression of the A (PRA) and B (PRB) isoforms of PR. In mifepristone (MFP)-resistant murine carcinomas antiprogestin responsiveness was restored by re-expressing PRA using demethylating agents and histone deacetylase inhibitors. Consistently, in two human breast cancer xenograft models, one manipulated to overexpress PRA or PRB (IBH-6 cells), and the other expressing only PRA (T47D-YA) or PRB (T47D-YB), MFP selectively inhibited the growth of PRA-overexpressing tumors and stimulated IBH-6-PRB xenograft growth. Furthermore, in cells with high or equimolar PRA/PRB ratios, which are stimulated to proliferate in vitro by progestins, and are inhibited by MFP, MPA increased the interaction between PR and the coactivator AIB1, and MFP favored the interaction between PR and the corepressor SMRT. In a PRB-dominant context in which MFP stimulates and MPA inhibits cell proliferation, the opposite interactions were observed. Chromatin immunoprecipitation assays in T47D cells in the presence of MPA or MFP confirmed the interactions between PR and the coregulators at the CCND1 and MYC promoters. SMRT downregulation by siRNA abolished the inhibitory effect of MFP on MYC expression and cell proliferation. Our results indicate that antiprogestins are therapeutic tools that selectively inhibit PRA-overexpressing tumors by increasing the SMRT/AIB1 balance at the CCND1 and MYC promoters.