Endoscopic landmarks corresponding to anatomical landmarks for esophageal subsite classification

Objectives

Individual treatment strategies for esophageal cancer have been investigated based on the anatomical subsite classification. Accurate subsite classification based on these anatomical landmarks is thus important. We investigated the suitability of the existing endoscopic classification and explored alternative landmarks for esophageal subsite classification.

Methods

Patients who received endoscopic ultrasonography (and computed tomography scans for surveillance of esophageal cancer treatment or esophageal submucosal tumors were included. Distances between anatomical landmarks, including the inferior cricoid cartilage border, superior border of the sternum, and tracheal bifurcation, were measured using a combination of endoscopic ultrasonography, computed tomography, and other information.

Results

The mean (standard deviation) distances from the superior incisor dentition to the pharynx-esophagus, cervical-upper thoracic esophagus, and upper-middle thoracic esophagus boundaries were 16.9 (1.7), 21.7 (1.9), and 29.0 (1.9) cm, respectively. However, variances in the differences between the mean and individual distances were large (2.8, 3.4, and 3.7, respectively), mainly because of differences in body height. However, variances in the differences between individual distances and novel endoscopic landmarks, including the lower end of the pyriform sinus and lower end of compression of the left main bronchus, were lower (1.7, 1.2, and 0.6, respectively).

Conclusions

Existing indicators of esophageal subsite boundaries were not consistent with anatomical boundaries. Modification of the distance from the superior incisor dentition based on average distances from anatomical landmarks or the use of alternative endoscopic landmarks is recommended to provide more suitable anatomical boundaries.

Salvage treatment after endoscopic submucosal dissection for a rectal neuroendocrine tumor: Premeditated peranal endoscopic myectomy

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Predictors of technical difficulty for trainees in esophageal endoscopic submucosal dissection

BACKGROUND

Esophageal endoscopic submucosal dissection (ESD) is technically challenging, especially for trainees, and requires a safe training system. This study aimed to identify predictors of technical difficulty facing trainees performing esophageal ESD to establish such system.

METHODS

This was a single-center retrospective study of patients with esophageal cancer who underwent ESD performed by trainees between January 2010 and August 2022. Technical difficulties were defined as muscularis propria exposure and long procedure time (≥ 90 min). Factors associated with these technical difficulties were investigated.

RESULTS

A total of 798 lesions in 721 patients were evaluated. Muscularis propria exposure occurred in 298 lesions (37.3%), including 10 perforations (1.3%). The procedure time was ≥ 90 min in 134 lesions (16.8%). In the multivariate analysis, tumor size ≥ 20 mm, tumors ≥ 1/2 of the circumference, and those close to previous treatment scars significantly increased the incidence of both difficulties, whereas tumors in the upper esophagus significantly decreased this incidence. Furthermore, female sex and tumors in the left wall were independent predictors of muscularis propria exposure, and elevated morphology was an independent predictor of long procedure time. Muscularis propria exposure and long procedure time occurred in more than half of the cases with three or more predictors of each difficulty.

CONCLUSIONS

Large tumors and tumors close to previous treatment scars increase technical difficulties for trainees in esophageal ESD. Conversely, tumors in the upper esophagus reduce these difficulties. These results enable us to predict the difficulty level preoperatively and select appropriate cases in stepwise training.

Esophageal rupture during endoscopic submucosal dissection closed using a novel suturing device

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A case of pyloric gland adenoma with high-grade dysplasia in the duodenum arising from heterotopic gastric mucosa observed over 5 years

Pyloric gland adenoma (PGA) in the duodenum is a rare gastric phenotype duodenal neoplasm. Although heterotopic gastric mucosa in the duodenum has been recognized as a benign lesion, it is a potential precursor of PGA and gastric phenotype adenocarcinoma. Herein, we present a case follow-up of endoscopic and histological changes in the PGA in the duodenum from low-grade to high-grade dysplasia. PGA was considered to arise from the heterotopic gastric mucosa, because the heterotopic gastric mucosa was observed in the initial examination. It is difficult to distinguish heterotopic gastric mucosa from PGAs, both endoscopically and histologically. This increase in size may be useful for their differentiation. Therefore, endoscopists should not underestimate the growth of the heterotopic gastric mucosa compared to that in the previous examination.

Lustrous White Erosions Surrounded by an Erythematous Mucosa: A Novel Endoscopic Finding of Gastric Lesions in Patients with Wilson Disease

Wilson disease is an inherited copper metabolism disorder. We herein report a novel endoscopic finding in three men with Wilson disease. These patients underwent upper endoscopy due to gastrointestinal symptoms or during follow-up. In each case, endoscopy revealed lustrous white erosions surrounded by an erythematous mucosa in the greater curvature of the gastric body. A biopsy of the lesions showed orcein-positive tissue, indicating copper deposition, in the interstitial stroma and fundic glands of the mucosa. All patients had been receiving treatment with zinc acetate. These endoscopic findings might have been related to the cytotoxicity of the accumulated copper and zinc acetate.

Efficacy of Ninjin'yoeito in treating severe coronavirus disease 2019 in patients in an intensive care unit

Coronavirus Disease-2019 (COVID-19), an infectious disease associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is a global emergency with high mortality. There are few effective treatments, and many severe patients are treated in an intensive care unit (ICU). The purpose of this study was to evaluate whether the Japanese Kampo medicine ninjin'yoeito (NYT) is effective in treating ICU patients with COVID-19. Nine patients with confirmed SARS-CoV-2 infection admitted to the ICU were enrolled in this study. All patients underwent respiratory management with invasive mechanical ventilation (IMV) and enteral nutrition. Four patients received NYT (7.5 g daily) from an elemental diet tube. We retrospectively examined the prognostic nutritional index (PNI), length of IMV, length of ICU stay, length of hospital stay, rate of tracheostomy, and mortality rate. The median age of the enrolled participants was 60.0 years (4 men and 5 women). The median body mass index was 27.6. The most common comorbidity was diabetes (4 patients, 44%), followed by hypertension (3 patients, 33%) and chronic kidney disease (2 patients, 22%). The median length of IMV, ICU stay, and hospital stay were all shorter in the NYT group than in the non-NYT group (IMV; 4.0 days vs 14.3 days, ICU; 5.3 days vs 14.5 days, hospital stay; 19.9 days vs 28.2 days). In the NYT and non-NYT groups, the median PNI at admission was 29.0 and 31.2, respectively. One week after admission, the PNI was 30.7 in the NYT group and 24.4 in non-NYT group. PNI was significantly (p = 0.032) increased in the NYT group (+13.6%) than in the non-NYT group (-22.0%). The Japanese Kampo medicine NYT might be useful for treating patients with severe COVID-19 in ICU. This study was conducted in a small number of cases, and further large clinical trials are necessary.

Abstract OT2-01-05: A randomized controlled trial comparing post-operative intensive follow-up with standard follow-up in high-risk breast cancer patients (JCOG1204: INSPIRE)

Background: The standard follow-up after surgery for breast cancer includes periodic interviews, clinical examinations, and mammography, but many institutions are conducting intensive follow-up including periodic computed tomography(CT), magnetic resonance imaging(MRI), and bone scintigraphy in the world, despite the lack of evidence to support this approach. While intensive follow-up may contribute to prolonged survival through earlier diagnosis and treatment of relapse, it has the disadvantages of high effort and costs placed on patients(pts) and healthcare workers, radiation exposure for imaging examinations, and overtreatment owing to false-positive results. Although past two randomized trials could not show significant difference in overall survival (OS), as imaging methods have remarkably improved, leading to the earlier detection of relapse, and medical therapies have remarkably improved in recent years, randomized controlled trials are needed to confirm whether intensive follow-up can really prolong survival sufficiently to offset these disadvantages in high-risk breast cancer pts.

Trial design: This study is a multi-institutional two-arm open label randomized controlled phase III trial being conducted with the participation of 42 hospitals belonging to the Breast Cancer Study Group of Japan Clinical Oncology Group. Eligible pts are randomized either to the intensive follow-up group or to the standard follow-up group; the former will undergo physical examination, bone scintigraphy, chest and abdominal CT, brain MRI/CT and frequent tumor markers, whereas the latter will undergo physical examination at the same frequency and tumor markers will be evaluated once a year. Mammography once a year is planned for both groups. This trial has been registered at the UMIN Clinical Trials Registry as UMIN000012429.

Eligibility criteria: High-risk breast cancer pts, who are expected to have recurrence rates of over 30% within 5 years after surgery. The main inclusion criteria are as follows: four or more axillary nodal metastases in the estrogen receptor (ER) positive pts without neoadjuvant chemotherapy(NC)., axillary node metastases in ER-negative pts without NC, axillary nodal metastases in ER-positive pts with NC, histologically proven residual invasive cancer in the breast or axilla in ER-negative with NC.

Specific Aims: The primary endpoint is OS, and secondary endpoints are disease-free survival, relapse-free survival, distant metastasis–free survival, OS in intrinsic subtypes, actual number of implemented examinations, compliance with pre-specified examinations, and adverse events.

Statistical methods: The primary endpoint will require a total of 538 events to be assessed in order to obtain a statistical power of 80% with a one-sided significance level of 0.05. Thus, the planned sample size to compare the two survival curves is set at 1500 pts, assuming an accrual time of 6 years and a follow-up time of 7 years according to the Schoenfeld and Richter's method.

Present accrual and target accrual: The trial was activated in November 2013. 773 pts have been enrolled by the end of June 2018.

Contact: Principal investigator Takashi Hojo MD tahojo@east.ncc.go.jp

Citation Format: Hojo T, Masuda N, Shibata T, Mizutani T, Shien T, Kinoshita T, Iwatani T, Kanbayashi C, Kitagawa D, Tsuneizumi M, Iwata H. A randomized controlled trial comparing post-operative intensive follow-up with standard follow-up in high-risk breast cancer patients (JCOG1204: INSPIRE) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-01-05.

Chemoimmunotherapeutic effect of combined treatment with ex vivo generated antigen-presenting immune cells and conventional antitumor agents in a mouse neuroblastoma model

PURPOSE

Combining antitumor immunotherapy with conventional intensive multimodal therapy may be considered for advanced neuroblastoma. We investigated combination therapy with ex vivo generated immunostimulatory cells and intraperitoneal doxorubicin.

METHODS

Immunogenic death of neuro-2a neuroblastoma cells was induced by doxorubicin or cisplatin (negative control). Mouse bone marrow cells were cultured with granulocyte-macrophage colony-stimulating factor, followed by addition of doxorubicin-killed neuro-2a cells with or without interleukin-4 and/or CpG-oligodeoxynucleotide to induce immunostimulatory cells. CD8α⁺ lymphocytes were cocultured with killed neuro-2a cells and immunostimulatory cells, and interferon-γ was measured in the supernatant. Furthermore, female A/J mice were injected with viable neuro-2a cells, followed by immunostimulatory cells and doxorubicin. Then intraabdominal tumor nodules were evaluated.

RESULTS

Bone marrow-derived immunostimulatory cells only promoted interferon-γ production by CD8α⁺ lymphocytes after first being stimulated by doxorubicin-killed neuro-2a cells and interleukin-4, followed by CpG-oligodeoxynucleotide. These cells had a surface antigen expression profile compatible with activated dendritic cells and suppressed tumors in mice intravenously injected with neuro-2a cells. Despite a similar surface antigen profile, the in vivo antitumor effect was stronger after injection of immunostimulatory cells induced by doxorubicin-killed neuro-2a cells compared with cells induced by cisplatin-killed neuro-2a cells. Moreover, interferon-γ production was greater when CD8α⁺ lymphocytes were cocultured with doxorubicin-killed neuro-2a cells and immunostimulatory cells rather than with cisplatin-killed cells.

CONCLUSION

Cells with antitumor activity can be induced from bone marrow cells. Combining such cells with doxorubicin may activate antitumor immunity in tumor-bearing mice. Interactions between induced immunostimulatory cells and conventional chemotherapy might be important for antitumor immunity.

Acute gastric volvulus associated with wandering spleen in an adult treated laparoscopically after endoscopic reduction: a case report

A 43-year-old female was referred to our hospital for sudden onset of abdominal pain, fullness, and vomiting. Physical examination revealed abdominal distension with mild epigastric tenderness. Abdominal radiography showed massive gastric distension and plain computed tomography (CT) a markedly enlarged stomach filled with gas and fluid. A large volume of gastric contents was suctioned out via a nasogastric (NG) tube. Contrast-enhanced CT showed a grossly distended stomach with displacement of the antrum above the gastroesophageal junction, and the spleen was dislocated inferiorly. Upper gastrointestinal (GI) series showed the greater curvature to be elevated and the gastric fundus to be lower than normal. Acute mesenteroaxial gastric volvulus was diagnosed. GI endoscopy showed a distortion of the gastric anatomy with difficulty intubating the pylorus. Various endoscopic maneuvers were required to reposition the stomach, and the symptoms showed immediate and complete solution. GI fluoroscopy was performed 3 days later. Initially, most of the contrast medium accumulated in the fundus, which was drawn prominently downward, and then began flowing into the duodenum with anteflexion. Elective laparoscopic surgery was performed 1 month later. The stomach was in its normal position, but the fundus was folded posteroinferiorly. The spleen attached to the fundus was normal in size but extremely mobile. We diagnosed a wandering spleen based on the operative findings. Gastropexy was performed for the treatment of gastric volvulus and wandering spleen. The patient remained asymptomatic, and there was no evidence of recurrence during a follow-up period of 24 months. This report describes a rare adult case of acute gastric volvulus associated with wandering spleen. Because delay in treatment can result in lethal complications, it is critical to provide a prompt and correct diagnosis and surgical intervention. We advocate laparoscopic surgery after endoscopic reduction because it is a safe and effective procedure with lower invasiveness.

Ex vivo induction of antitumor DEC-205+ CD11c+ cells in a murine neuroblastoma model by co-stimulation with doxorubicin, lipopolysaccharide and interleukin-4

The antigen-presenting capacity of specific cells and tumor immunogenicity involved in innate cellular immunity are important for initiating an antitumor response to advanced neuroblastoma. The present study was performed to establish a method of producing antigen-presenting cells that induced an immune response to murine neuroblastoma cells through culture with neuroblastoma cells that had undergone immunogenic cell death. Immunogenic death of neuro-2a murine neuroblastoma cells was induced by exposure to doxorubicin. Mouse bone marrow cells were cultured in medium containing granulocyte-macrophage colony-stimulating factor, followed by the addition of doxorubicin-treated neuro-2a cells to the culture with or without lipopolysaccharide (LPS) and/or interleukin-4. Subsequently, cluster of differentiation (CD) 8α⁺ lymphocytes were co-cultured with neuro-2a cells and the adherent bone marrow cells obtained by the above procedure to evaluate CD8α⁺ lymphocyte proliferation and interferon-γ production. Furthermore, the surface antigen profile of adherent bone marrow cells was analyzed by flow cytometry. When adherent bone marrow cells were treated with LPS and/or interleukin-4, followed by co-culture with CD8α⁺ lymphocytes and neuro-2a cells, interferon-γ production by the CD8α⁺ cells increased in response to anti-CD3/CD28 antibody stimulation. CD11c major histocompatibility complex II (MHC II) double-positive cells were increased among adherent cells derived from cultured bone marrow cells. These cells were positive for DEC-205, but not CD8α. These findings suggest that co-culture of bone marrow-derived cells with tumor cells (that have undergone immunogenic death by exposure to doxorubicin) plus stimulation by LPS and interleukin-4 induces antigen-presenting cells that can evoke an immune response to neuroblastoma. Bone marrow-derived DEC-205⁺ CD11c⁺ MHC II⁺ dendritic cells are key antigen-presenting cells in the induction of an immune response following phagocytosis of doxorubicin-treated neuroblastoma cells.

Abstract P2-10-04: The clinicopathological features of androgen receptor expression in primary HER2-positive breast carcinomas

Background: Human epidermal growth factor receptor 2 (HER2)-positive breast carcinomas are aggressive subtypes associated with a variable response to systemic therapies. HER2-positive breast carcinomas are not homogeneous, and it has been reported that androgen receptor (AR) signaling is an important determinant of cell growth and relation with HER3 expression. The aim of this study was to investigate the clinicopathological significance of AR expression in primary HER2-positive breast carcinomas.

Patients and Methods: 102 primary HER2-positive breast tumor samples were obtained from patients operated on at the Cancer and Infectious Disease Center, Tokyo Metropolitan Komagome Hospital from 2001 to 2010. 92 tumors were IHC (HercepTest) score 3, whereas 10 were IHC score 2 and FISH- positive. We evaluated AR using immunohistochemistry. Tumors with equal or more than 10% nuclear-stained cells were determined to be positive for AR and the relationship between AR and clinicopathological parameters was analyzed.

The expression of HER3 was evaluated by immunohistochemistry using the following scoring system: 0 (no staining), 1 (less than 20% of cells stained or weak staining), 2 (more than or equal to 20% of cells stained, or strong staining) and the relation with AR expression was examined.

The differences among variables were calculated by chi-square test.

Results: The median age of all patients was 56 years old (from 31 to 84). AR-positive carcinomas corresponded to 37(36.2%) of 102 HER2-positive breast carcinomas. The median age of AR-positive patients was 54 years old while that of AR-negative patients was 57 years old. There was no significant difference between the two groups.

AR-positive carcinomas were not associated with ER and progesterone receptor (PgR) co-expression and nuclear grade. The stage distribution of AR-positive patients was: stage I(n = 23), stage IIA(n = 11), stage IIB (n = 3), and averaged 18.5mm in tumor size, while AR-negative patients distributed as stage I(n = 16), stage IIA(n = 27), stage IIB (n = 15), stage IIIA(n = 5), stage IIIB(n = 2), and averaged 23.7mm in size. AR-positive carcinomas were associated with larger pathological tumor size and more advanced clinical stages, though lymph node involvement did not differ between the two groups.

The HER3 expression score distribution was: scrore 0 (n = 14), score 1 (n = 54), score 2 (n = 34). The expression of HER3 was not associated with clinicopathological parameters. Furthermore, there was no significant relation between AR expression and HER3 expression.

Median follow-up interval was 63 months. 20 patients (19.6%) suffered recurrence. Four patients suffered recurrence in the AR-positive group while there were 16 patients in the AR-negative group. AR-positive patients had significant better prognosis in recurrence than AR-negative patients.

Conclusion: Among HER2-positive breast carcinomas, AR-positive carcinomas have the tendency to be smaller in tumor size and of early clinical stage compared with those that are AR-negative. The expression of AR might be a better prognostic factor in HER2-positive breast carcinomas.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-10-04.

Abstract P6-11-11: Characteristics of long-term survivors after brain metastases in breast cancer patients

Background: Brain metastases (BM) occur in 10%-15% patients of breast cancer patients. It is associated with poor prognosis, requiring great effort to manage local and systemic treatment for BM. The purpose of this study was to analyze the clinico-pathological characteristics of long-term survivors with BM in breast cancer patients.

Method: 63 patients with breast cancer BM diagnosed from 2002 to 2010 at the Tokyo Metropolitan Komagome hospital were included. Long–term survival group (Long) was defined as to be consisted of the patients with survival duration more than 36 months after diagnosed with BM and the patients with less than 36 month was into Short-term survival group (Short) in this study. The clinico-pathological characteristics were compared between these two groups. Survival rate and prognostic factors of BM were analyzed by the Kaplan–Meier method and employed by Log–Rank test. Multivariate analysis was performed by the Cox proportional hazard model.

Results: Median age of the 63 patients was 53 years (range, 35–78). Median survival time after BM was 12 months (range, 1–168), with about 90 percent of cause of death related to BM (e.g. failure of PS due to BM). As for ER and HER2 status, the number of ER+/HER2- (Luminal:Lum), ER+or-/HER2+ (HER2-enrich:Her2-E), ER-/HER2- (Basal:Bas) were 18, 27, 18, respectively. Among those 63 patients, 11 survived 36 months or more after BM. However, there was no difference in the rate of ER status between Long (55%) and Short (38%), there were significantly high rate of Her2-E case in Long (73%) as compared with Short (29%). Median survival duration after diagnosed with BM of Lum, Her2-E and Bas were 11, 37, 3 months, respectively. Prognosis of Bas was significantly poor (Bas vs. Her2-E p<0.001), and although Her2-E was not significant as compared with ER (p = 0.188), survival time after BM of Her2-E was the tendency to be long. In univariate analysis, Karnofsky performance status (KPS≥70 or <70), HER2 status, disease free interval (from initial diagnosis to first recurrence, DFI≥2years or <2years) had significant impact on survival time after BM. (p = 0.0458, 0.0398, 0.0385, respectively). Meningitis status was a borderline. (p = 0.052) In multivariate analysis, KPS, HER2 status and DFI were significant prognostic factors. (KPS: RR 2.08, 95% CI 1.08-4.07; HER2: RR 2.911, 95% CI 1.396- 6.484; DFI: RR 1.933, 95% CI 0.83-4.102)

Conclusions: Although, it was believed that the prognosis after BM was poor, Her2-E BM had a comparatively good prognosis. An existing report supports extension of the survival time after BM by HER2–targeted treatment in BM cases with Her2 positive breast cancer. This newest study reviles the median survival after BM as 37 months in Her2-E BM group, but that of Bas group was only 3 months and this is not improved at all compared with historically reported survival duration (2.4-4.9months). Our reports suggested that the innovation of Her2–targeted treatment leads this surprising improvement of life extension in HER2 positive BM patients but innovation of cytotoxic agents could not contribute toward improvement of clinical outcome in triple negative BM patients. So the necessity of examining the medical treatment of breast cancer BM according to subtype from now on is also considered.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-11-11.

Correlation between aquaporin and water permeability in response to vasotocin, hydrin and {beta}-adrenergic effectors in the ventral pelvic skin of the tree frog Hyla japonica

The ventral pelvic skin of the tree frog Hyla japonica expresses two kinds of arginine vasotocin (AVT)-stimulated aquaporins (AQP-h2 and AQP-h3), which affect the capacity of the frog's skin to absorb water. As such, it can be used as a model system for analyzing the molecular mechanisms of water permeability. We investigated AQP dynamics and water permeability in the pelvic skin of H. japonica following challenge with AVT, hydrins (intermediate peptides of pro-AVT) and beta-adrenergic effectors. In the in vivo experiment, both AQP-h2 and AQP-h3 proteins were translocated to the apical plasma membrane in the principal cells of the first-reacting cell (FRC) layer in the pelvic skin following challenge with AVT, hydrin 1 and hydrin 2, thereby increasing the water permeability of the pelvic skin. The beta-adrenergic receptor agonist isoproterenol (IP) and its anatagonist propranolol (PP) in combination with AVT or hydrins were used as challenge in the in vitro experiment. IP increased water permeability whereas PP inhibited it, and both events were well correlated with the translocation of the AQPs to the apical membrane. In the PP+AVT-treated skins, labels for AQP-h2 and AQP-h3 were differentially visible among the principal cells; the apical plasma membrane of some cells was labeled while others were not, indicating that the response of PP or AVT is different from cell to cell. These results provide morphological evidence that the principal cells of the FRC layers may have two kinds of receptors: a V2 receptor and beta-adrenergic receptor.

A low number of tumor infiltrating FOXP3-positive cells after primary systemic chemotherapy is correlated with favorable relapse-free survival in breast cancer patients

Abstract #5043

Background: Cancer cells induce proliferation and local accumulation of immunosuppressive cells such as FOXP3-positive cells which known as regulatory T cells (Tregs). Tregs prevent the maturation of dendritic cells and their capacity to present tumor antigens to cytotoxic T lymphocytes (CTLs) and leads to tumor-induced tolerance. Although cancer chemotherapy was usually considered as immunosuppressive, some chemotherapeutic agents have recently been shown to activate an anticancer immune response, which is involved in the curative effect of these treatments. Therefore, we hypothesized that number of tumor infiltrating FOXP3-positive cells during primary systemic chemotherapy is correlated with therapeutic results in breast cancer patients.
 Methods: To test the hypothesis, between September 2000 and January 2005, breast cancer patients treated with primary systemic chemotherapy (PSC) (n=93) were included in the study. Three cases were excluded because main tumors were resected before PSC and three cases of pathological complete reaction were excluded because they were hard to define “tumor infiltrating” Tregs. To compare the number of FOXP3 positive cells in the tumors before and after PST, both core-needle biopsy (CNB) and surgical resected specimens were stained with FOXP3 monoclonal antibody. Numbers of tumor infiltrating FOXP3-positive cells were counted in 3 and 5 randomly chosen high power fields (CNB and surgical specimens, respectively). A median cutoff of >16.3 and > 6.6 defined patients with high numbers of Tregs (CNB and surgical specimens, respectively). We also divided the patients into four groups (high numbers of FOXP3 positive cells in both CNB and surgical specimens; HH, low numbers in the both specimens; LL, high numbers in CNB and low in the surgical specimens; HL, and low in CNB and high in surgical specimens; LH). All patients were treated with anthracyclin containing therapy and 79.3 %( n=69) of them were added taxanes sequentially.
 Results: In the tumors after PST, numbers of Tregs were significantly higher in lymphvessel invasion positive tumors (P=0.01) and ER negative tumors (P=0.02) but there was no correlation between lymph node involvement and numbers of Tregs (P=0.8). As for the comparison of four groups, LL group shows the longest relapse-free (P=0.04) and overall survival (P=0.09) and HH group shows the shortest relapse-free and overall survival among four groups. Interestingly, HL group shows better outcome than HH group and LH group shows worse one than LL.
 Conclusions: These findings suggest that the control of Tregs in the tumor is important for the control of the disease and Tregs might be an important therapeutic target for breast cancer. Furthermore, it is suggested that some chemotherapeutic agents could be a potential inhibitor of the Tregs in tumor and show antitumor effects addition to their direct cytotoxicity against cancer cells.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5043.

The alternation of estrogen receptor (ER) and progesterone receptor (PgR) expression in primary breast cancer patients treated with neoadjuvant chemotherapy (NAC)

21165

Background: Currently, neoadjuvant chemotherapy (NAC) for the operable primary breast cancer has become standard treatment strategy. Primary treatment could affect the status of Estrogen receptor (ER) and Progesterone receptor (PgR) expressions in the tumor, and might have impact on the choice of adjuvant hormone therapy. Methods: We evaluated consecutive 165 primary breast cancer cases those treated with 4 cycles of FEC (500–100–500 mg/m2, q3wks) followed by 4 cycles docetaxel (75 mg/m2, q3wks) as their neoadjuvant treatment in our institution from January 2000 to February 2006. Except for the bilateral breast cancer cases and patients achieved pCR, 107 pairs of core needle biopsy before treatment and tumor block after surgery were evaluated by immunohistochemistry (IHC) for receptor status and analyzed by Allred scoring. Score 4 or more was designated as positive. Results: Median age of patients was 51 (23–71) years old. Hormone receptor (HR) phenotypes before treatment were following; ER+/PgR+:62(57.9%), +/ -:23(21.5%), -/ +:2(1.9%), -/ -:20(18.7%). As the HR status, 94.4 % of patients did not show any alternation for their HR evaluation. Only 4.7% of patients experienced changes from HR+ to HR-, and HR- to HR+ were extremely rare (0.9%). Although ER positivity was not changed in most of cases (95.1%), conversion from PgR + to - were observed in 35.5% of ER+/PgR+ cases. Particularly, the rate of negative conversion of PgR were found more frequently in patients with age under 50 (51.7% in <50y.o. vs. 22.6% in =50 y.o., p=0.03). Whereas, in older patients, negative conversion of PgR correlated to favorable pathological response. Conclusions: In most of patients, neoadjuvant chemotherapy did not affect the evaluation of HR status. Alternation of PgR expression seems to reflect the chemotherapy induced amenorrhea in younger patients. In the older patients, negative conversion of PgR may have some impact on pathological response.

No significant financial relationships to disclose.

Adding paclitaxel to trastuzumab enhances antibody-dependent cell-mediated cytotoxicity via increment of natural killer cells in patients with Her-2 overexpressing breast cancer

10548

Background: One of the mechanisms by which trastuzumab (TZ) inhibits the growth of Her-2 overexpressing breast cancer cells is the activation of a host tumor response via antibody-dependent cell-mediated cytotoxicity (ADCC). We questioned whether adding PTX to TZ enhances ADCC and also investigated kinetics of effector cells in ADCC. Methods: In ADCC, 5 cases with metastatic breast cancer receiving TZ (4mg/kg as a loading and 2 mg/kg weekly) with PTX (2qw, 100 mg/m2) were investigated. ADCC was analyzed by 51Cr releasing assay using SK-BR-3 cell line and white blood cells taken at the time of pretreatment, after 4 mg/kg of TZ, before/after 2 mg/kg of TZ, and before/after 2 mg/kg of TZ plus PTX. In of effector cell studies, we investigated fractions of natural killer (NK) cell, monocyte, and neutrophil taken at pre-administration and 10 minutes post-administration in 16 patients with Her-2 overexpressing breast cancer receiving weekly TZ and PTX (80 mg/m2). We defined NK cells as being both CD16+ (FcγRIII) and CD56+ and neutrophils as CD64+ (FcγRI) by flow cytometry. Results: Compared with pretreatment ADCC level, cytotoxicity were enhanced to 220% (median, ranging 30–259) after 4 mg/kg of TZ, 129% (78–210) after 2 mg/kg of TZ, and 148% (42–557) after the combination of TZ and PTX, whereas suppressed to 94% (48–163) after PTX alone. 2 weeks after the combination therapy, ADCC was significantly enhanced to 169% (113–257, p<0.05), compared with pre-treatment. In effector cells, NK cells increased in 131% (74–175, p<0.05) by TZ and in 224% (169–286, p<0.05) by the combination therapy. No significant changes were found in monocytes (98%, 50–160) and in neutrophils (100%, 50–160) by TZ alone, however monocytes decreased to 44% (34–50, p<0.05) and also neutrophils did to 49% (9–133) by the combination. Conclusions: Higher doses of TZ induced NK cell recruitment and the combination of TZ and PTX has a significant increase in recruitment and activation of NK cells. Adding PTX to TZ significantly enhanced ADCC via the rapid kinetics of NK cells. This may reflect that the combination of TZ and PTX has a strong synergistic effect than we expected in patients with Her-2 overexpressing breast cancer.

[Table: see text]

Impaired synergistic activation of stress-activated protein kinase SAPK/JNK in mouse embryonic stem cells lacking SEK1/MKK4: different contribution of SEK2/MKK7 isoforms to the synergistic activation

Stress-activated protein kinase/c-Jun NH(2)-terminal kinase (SAPK/JNK), which is a member of the mitogen-activated protein kinase (MAPK) family, plays an important role in a stress-induced signaling cascade. SAPK/JNK activation requires the phosphorylation of Thr and Tyr residues in its Thr-Pro-Tyr motif, and SEK1 (MKK4) and MKK7 (SEK2) have been identified as the upstream MAPK kinases. Here we examined the activation and phosphorylation sites of SAPK/JNK and differentiated the contribution of SEK1 and MKK7alpha1, -gamma1, and -gamma2 isoforms to the MAPK activation. In SEK1-deficient mouse embryonic stem cells, stress-induced SAPK/JNK activation was markedly impaired, and this defect was accompanied with a decreased level of the Tyr phosphorylation. Analysis in HeLa cells co-transfected with the two MAPK kinases revealed that the Thr and Tyr of SAPK/JNK were independently phosphorylated in response to heat shock by MKK7gamma1 and SEK1, respectively. However, MKK7alpha1 failed to phosphorylate the Thr of SAPK/JNK unless its Tyr residue was phosphorylated by SEK1. In contrast, MKK7gamma2 had the ability to phosphorylate both Thr and Tyr residues. In all cases, the dual phosphorylation of the Thr and Tyr residues was essentially required for the full activation of SAPK/JNK. These data provide the first evidence that synergistic activation of SAPK/JNK requires both phosphorylation at the Thr and Tyr residues in living cells and that the preference for the Thr and Tyr phosphorylation was different among the members of MAPK kinases.