Abstract P3-10-15: Quantitative Gene Expression by RT-PCR in Classic and Variant Forms of Lobular Carcinoma in Estrogen Receptor Positive Invasive Breast Cancer

Background: Classic lobular carcinoma is characterized by a distinctive morphology, loss of E-cadherin commonly due to mutation or deletion of CDH1 on chromosome 16q, and a variable clinical course (Pestalozzi J Clin Oncol. 2008 26:3006). Variants (pleomorphic, solid and alveolar) with distinct morphologies and potential differences in outcome have been described (Rosen 2009). Herein we explore the patterns of quantitative gene expression as measured by the 21 gene Oncotype DX® assay observed between ductal NOS (DC) and classic and variant lobular carcinomas. Material and Methods: All tumors analyzed in the Genomic Health laboratory from 6/1/04-3/31/10 were included. Central path used WHO criteria for classification of classic lobular (CL), solid & alveolar lobular (SAL), and pleomorphic lobular (PL) carcinomas. Quantitative expression of 16 cancer related genes was measured on a scale from 0 to 15 (relative to reference genes) where a 1 unit increment is associated with an ∼2-fold change in expression. Descriptive statistics for RS & individual genes [ER, PR, invasion gene group (IGG) & proliferation gene group (PGG)] among the different subtypes were obtained. Comparisons of means among the subtypes were adjusted to control the overall error rate under any complete or partial null hypothesis.

Results: DC accounted for 90.4% of 133,234 cases, CL 8.2%, SAL 0.7% and PL 0.8%. For all types a continuous range of RS was observed. DC had the greatest percentage of high risk RS followed by SAL, PL and CL. DC had the highest RS and CL had the lowest RS. SAL had the highest ER expression and CL had the lowest expression, but these results may refect a submission bias and are not population based. The proportion with the ER+/PR-phenotype was slightly different among the subtypes: SAL (24.2%) and PL (19.5%) had a higher incidence compared to DC (15%) and CL (15.6%). SAL had the highest PGG expression; CL had the lowest. DC had the highest IGG; CL had the lowest.

Discussion: Classic lobular carcinoma and the lobular carcinoma variants are characterized by differential patterns of gene expression. Outlier cases are not infrequent within each of the special subtypes in this large observational cohort. The variation in gene expression, noted by histologic subtype, will be presented in detail.

RS Distributions in Ductal NOS, Lobular and Lobular Variants

When and why is blood crossmatched? A prospective survey of transfusion laboratory practice in two regions in the north of England

BACKGROUND AND OBJECTIVES

This study was undertaken to provide data relating to the timing of laboratory crossmatch procedures, and the source of requests for out of hours crossmatch, to support interpretation of error reports originating in the transfusion laboratory, received by the Serious Hazards of Transfusion haemovigilance scheme.

MATERIALS AND METHODS

Data on the timing, origin and urgency of all crossmatch requests were collected in 34 hospitals in northern England over a 7-day period in 2008. Additional data on clinical urgency were collected on crossmatches that were performed out of hours.

RESULTS

Data were obtained on 2423 crossmatches, including 610 (25.2%) performed outside core hours. 30.3% of out of hours crossmatch requests were for transfusions that were set up outside 4 h of completion of the crossmatch.

CONCLUSION

2008 Serious Hazards of Transfusion data showed that 29/39 (74%) of laboratory errors resulting in 'wrong blood' occurred out of hours whilst our audit shows that only 25% of crossmatch requests are made in that time period, suggesting that crossmatching performed outside core hours carries increased risks. The reason for increased risk of error needs further research, but 25 laboratories had only one member of staff working out of hours, often combining blood transfusion, haematology and coagulation work. A total of 25% of out of hours requests were not clinically urgent. Hospitals should develop policies to define indications for out of hours transfusion testing, empower laboratory staff to challenge inappropriate requests and ensure that staffing and expertise is appropriate for the workload at all times.

Recognition, assessment and management of anaphylaxis

This article describes the physiological changes that take place during anaphylaxis, explores the ABCDE (airway, breathing, circulation, disability, exposure) approach to patient assessment and discusses the pharmacological interventions required to treat anaphylaxis effectively.

Oxidative and nitrosative stress in beta-cell apoptosis: their contribution to beta-cell loss in type 1 diabetes mellitus

The loss of beta-cell mass consequential to the activation of pro-apoptotic signalling events is increasingly recognised as a causal and committed stage in the development of autoimmune, type 1, diabetes mellitus (DM). While the mechanisms responsible for targeted beta-cell loss are multifaceted and difficult to define at a prediabetic stage, there is a need, from a therapeutic perspective, to understand the molecular mechanisms involved. Over recent years the use of animal and cell-line models of DM, together with investigations in isolated ex vivo human islets, have greatly increased our understanding of the processes involved in the pathogenesis of type 1 DM. From this work, several biochemical pathways have emerged that may have future potential for therapeutic intervention. This review looks at the current opinions on the role of apoptosis in beta-cell loss at the molecular level, focusing on a central mechanism for oxidative and nitrosative stress, and suggests biochemical pathways that may have future potential for therapeutic intervention.

Computer-enhanced insertion of the Oxford Unicompartmental arthroplasty: a Fluoroguide technique

OBJECTIVE

To develop an accurate and reproducible technique for inserting Oxford Unicompartmental arthroplasties.

MATERIALS AND METHODS

A protocol was developed to accurately position the femoral component of the Oxford Unicompartmental arthroplasty using computer-enhanced techniques. A dynamic reference body (DRB) is inserted into the femur, then antero-posterior (AP) and lateral fluoroscopic images are taken of the proximal femur. These images are digitized and entered into 3D space using a registered fluoroscopy machine. The femoral guide from the Oxford system is then placed on the medial femoral condyle in the standard manner. Holes are drilled directly towards the center of the femoral head using a registered drill. The femoral cuts are then made using the standard instruments from the Oxford set.

RESULTS

This procedure was carried out on 15 sawbone femurs. Component position was determined by measuring radiographs after a trial component had been inserted. The average lateral error was 1.2 degrees (standard deviation [SD] = 1.207), compared to 4.1 degrees (SD = 2.875) with the standard technique. The average AP error was 2.5 degrees (SD = 1.767), compared to 5.1 degrees (SD = 2.219) with the standard technique. The differences in accuracy in both planes were statistically significant (p = 0.002 for AP, 0.001 for lateral).

CONCLUSION

Using a Fluoroguide-assisted technique, we were able to insert the femoral component more precisely than when using the standard technique as described by the manufacturer.

Molecular characterization of male breast cancer by standardized quantitative RT-PCR analysis: First large genomic study of 347 male breast cancers compared to 82,434 female breast cancers

549

Background: Because male breast cancer (BC) is rare, there is little known about the disease and treatment is extrapolated from female BC. Newer molecular technologies have not been used to profile male BC. We report here a study of quantitative gene expression by gender status in tumor specimens submitted for Recurrence Score testing. Methods: All estrogen receptor positive tumor specimens successfully examined in the Genomic Health laboratory from June 2004 through December 2008 were included. Quantitative expression for each gene was measured by the 21 gene oncotype DX assay on a scale from 0 to 15 (relative to reference genes), where a one unit increment is associated with a 2-fold change in expression. Results: There were 347 male and 82,434 female BCs. The males were older (mean age 63.8 vs 57.4 yrs). Standard histopathology was similar, although slightly more male BCs were ductal (83% vs 78%). Like female BC, there was a wide variation in gene expression in male BC. The distribution of RS in males and females was similar - RS mean (±SD) 18.1 (±11.2) in males and 19.1 (±10.2) in females (p = NS). The proportion of tumors with RS <18, 18 - 30, and ≥ 31 was 53.6%, 35.2%, and 11.2% in males and 53.4%, 36.3%, and 10.3% in females. Although the patterns of expression of the Oncotype DX genes were more similar than different in males and females some differences were notable. Mean expression of ER, PR, and SCUBE2 were 0.5 units higher in males. Mean expression of the proliferation genes, Ki-67, MYBL2, Survivin, Cyclin B1, and STK15, were 0.5 units higher in males. Mean expression of STMY3 was 0.9 units higher in males. Of note, whereas the level of quantitative ER significantly increased with increasing patient age in females (0.4 units per decade), little increase was observed in males (<0.1 units per decade). Conclusions: This large genomic study of male BC reveals a heterogeneous biology as measured by the standardized quantitative oncotype DX breast cancer assay, similar to that observed in female BC. Some differences, which may reflect the differences in hormone biology between males and females, were noted and deserve further study.

[Table: see text]

A quantitative multigene RT-PCR assay for prediction of recurrence in stage II colon cancer: Selection of the genes in four large studies and results of the independent, prospectively designed QUASAR validation study

4000

Background: New clinical tools are needed to improve risk assessment and treatment decisions in stage II colon cancer. Four development studies [Surgery (Sx) alone: NSABP C-01/C-02 (n=270) and CCF study (n=765); Sx+5FU/LV: NSABP C-04 (n=308) and C-06 (n=508)] were performed to select the genes for prediction of recurrence and 5FU/LV benefit. To determine clinical utility of the prespecified assay, we performed a large, independent, prospectively designed, clinical validation study in stage II colon cancer pts from the QUASAR trial. Methods: Gene expression was quantitated by RT-PCR from 30 μm manually microdissected fixed paraffin-embedded primary colon cancer tissue. Recurrence-free interval (RFI), disease-free survival (DFS), and overall survival (OS) were analyzed using Cox regression. Results: Combined analysis of the four development studies (total n=1,851; 761 candidate genes) identified 48 genes significantly associated with recurrence risk and 66 genes predictive of 5FU/LV benefit. Multivariate analysis, in the context of stage, grade, nodes examined, and MSI status, yielded 18 genes (7 prognostic genes, 6 predictive genes, 5 reference genes) and separate prognostic recurrence score (RS) and predictive treatment score (TS) algorithms. In the QUASAR validation study, tumor blocks were collected for 68% of pts; 1,490 pts with blocks had stage II colon cancer and RT-PCR was successful in 1,436 eligible pts (711 Sx, 725 Sx+5FU/LV). Median FU=6.6 yrs. In the primary analysis of RFI in pts following Sx, the RS predicted recurrence risk (HR/25 units=1.58, 95% CI 1.15–2.15; p=0.004). The RS also predicted DFS (p=0.01) and OS (p=0.04). Recurrence risk increased monotonically with increasing RS. In multivariate analyses, RS retained prognostic significance (p=0.008) independent of mismatch repair (MMR), T stage, nodes examined, grade, and lymphovascular invasion. MMR deficiency (HR=0.31, 95% CI 0.15–0.63; p<0.001) and T4 stage (HR=1.94, 95% CI 1.35–2.79; p=0.005), together ∼25% of pts, also were independently prognostic. 5FU/LV benefit was significant (p<0.001). However, TS was not validated as a predictor of 5FU/LV benefit (interaction p=0.19). Conclusions: The colon cancer recurrence score is a validated, independent predictor of individualized recurrence risk for stage II colon cancer patients following surgery.

[Table: see text]

CALGB 140803—Association between cardiorespiratory fitness and overall survival in operable lung cancer patients: Ancillary analysis of protocol 9238

7518

Background: Cardiorespiratory fitness is a well-established independent predictor of all-cause mortality in a broad range of adult populations. The association between cardiorespiratory fitness and mortality has not been investigated among individuals diagnosed with cancer. We examined the association between cardiorespiratory fitness and all-cause mortality in 398 patients with non-small cell lung cancer (NSCLC). Methods: Using a prospective, observational design, patients with known or suspected NSCLC enrolled in CALGB 9238 were studied. Prior to pulmonary resection, all participants performed an incremental exercise test with expired gas analysis to assess cardiorespiratory fitness (i.e., peak oxygen consumption; VO2peak) and were observed for death or until June 2008. Cox proportional hazards models were used to estimate the risk of all-cause mortality according to cardiorespiratory fitness category defined by VO2peak (<0.96 / 0.96–1.29 / >1.29 L.min-1) with adjustment for age, gender, and performance status. Results: Of the 398 patients, 335 underwent surgical resection and 63 were deemed not eligible for resection. Median follow-up was 30.8 months, 294 deaths were reported during this period. For the entire sample, mortality rates declined across increasing VO2peak categories (adjusted Ptrend= 0.012). Compared with patients achieving a VO2peak <0.96 L.min-1, the adjusted hazard ratio (HR) for all-cause mortality was 0.64 (95% CI, 0.46 to 0.88) for a VO2peak of 0.96–1.29 L.min-1, and 0.56 (95% CI, 0.39 to 0.80) for a VO2peak of >1.29 L.min-1. The corresponding HRs for surgical patients were 0.65 (95% CI, 0.44 to 0.96) and 0.62 (95% CI, 0.42 to 0.90) relative to the lowest VO2peak category (ptrend=0.03), respectively. For non-surgical patients, the HRs were 0.74 (95% CI, 0.32 to 1.75) and 0.43 (95% CI, 0.18 to 1.00) relative to the lowest category (ptrend<0.04). Conclusions: Low VO2peak is associated with poorer survival among surgical candidates with NSCLC. Further work is required to investigate the prognostic value of objective measures of functional capacity in NSCLC and other cancer populations.

No significant financial relationships to disclose.

Acute Q-fever and history taking--a lesson learned

A 50-year-old patient underwent a routine primary total hip replacement. Soon after surgery, he developed acute respiratory failure from post-operative sepsis. His condition deteriorated rapidly despite supportive management and he required admission into intensive care unit for assisted ventilation. It took almost one week before the underlying cause of the deterioration was determined to be unrelated to complications of surgery. A diagnosis of Q-fever was made following detailed attention to the clinical history. Appropriate treatment was started and the patient made a full recovery. The diagnosis was confirmed later following discharge from hospital.

Evaluation of aromatase expression in mammographically dense and non-dense regions of the breast in healthy women

Abstract #4033

Background: Aromatase activity within the breast is a source of estrogen that may cause breast cancer. Mammographic density (MD) is a risk factor for breast cancer whose biologic basis is unknown. Our study compared aromatase expression in tissue from dense and non-dense areas of the breasts of healthy volunteers.&#x2028; Methods: Participants were 40+ yrs, had a screening mammogram with visible MD, no history of cancer and were not on endocrine therapy. Ultrasound-guided core biopsies were done within 6 months of mammography to obtain three paired cores from mammographically dense and non-dense regions of the breast. Immunostaining for aromatase expression employed the streptavidin-biotin amplification method using the recently developed 677 mouse monoclonal antibody. Immunoreactivity (IR) was scored in terms of proportion of cells staining positive for aromatase (PPC) (0=&lt;1%, 1=1-25%, 2=26-50%, 3=51+% (and 4=75%+ for adipocytes)) and relative immunointensity (0=none, 1=weak, 2=moderate, 3=intense) for each cell type (stroma, normal ductal epithelium, adipocytes). A composite score weighting the PPC by their relative intensity (range 0-9; 0-12 for adipocytes) was also calculated. The sum of the composite score across the three cell types provided a global assessment of aromatase IR. Repeated measures analyses evaluated differences in aromatase IR for dense compared to non-dense tissue within and across cell types. Parameter estimates (β) indicated the average difference between dense and non-dense IR.&#x2028; Results: 18 (37%) of the 49 participants were premenopausal (median age 46 yrs). Summing across cell types, the global composite score showed increased aromatase IR on sections sampled from dense vs. non-dense regions (β=5.3,p&lt;0.001). This global difference reflected increased aromatase IR in the stroma and normal ductal epithelium from dense sections (vs. non-dense). For 42 women with &gt;1% stromal cells on each section, there was evidence for increased IR on dense sections as indicated by the greater PPCs (β=0.9), relative intensity (β=0.7) and composite score (β=2.7)(p's&lt;0.001). Similarly, for 20 women with &gt;1% normal ductal epithelium in both dense and non-dense sections, there was a greater composite score (β=1.4,p=0.004) for cells on dense sections although differences for PPC (β=0.3,p=0.11) and relative intensity (β=0.3,p=0.09) did not reach statistical significance. No differences were seen in IR for adipocytes from the two density regions (46 women). Findings were unchanged with adjustment for covariates, including proportions of each cell type per section.&#x2028; Conclusions: There is strong evidence for increased aromatase expression in the stromal and normal ductal epithelium of dense vs. non-dense tissue. These results support ongoing research into mammographic density as a biomarker of effect of aromatase inhibitors.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4033.

Intra-articular injection composed of steroid, iohexol and local anaesthetic: is it stable?

The aim of this study is to determine the chemical stability of a suspension of steroid, radiographic contrast material and local anaesthetic. Image-guided steroid injection using a contrast material is widely used for several musculoskeletal conditions. Manufacturers of these agents do not advise mixture in a single syringe, as the chemical stability is unknown. They suggest that, if required, these agents should be injected separately. However, the agents will be mixed together when injected into a contained space within the body. It would seem unethical to continue this in clinical practice until the stability of such a mixture is established. High-performance liquid chromatographic (HPLC) analysis was used to assess the stability of combinations of steroids (triamcinolone and methylprednisolone) and Omnipaque (iohexol). Further analysis was also performed to test the stability of adding local anaesthetics (lidocaine and bupivacaine) to these mixtures. The results demonstrated that all combinations were stable when mixed together. In conclusion, these results support the continued safe use of these products in combination in clinical practice.