Mutational Landscapes of Smoking-Related Cancers in Caucasians and African Americans: Precision Oncology Perspectives at Wake Forest Baptist Comprehensive Cancer Center

Background: Cancers related to tobacco use and African-American ancestry are under-characterized by genomics. This gap in precision oncology research represents a major challenge in the health disparities in the United States. Methods: The Precision Oncology trial at the Wake Forest Baptist Comprehensive Cancer Center enrolled 431 cancer patients from March 2015 to May 2016. The composition of these patients consists of a high representation of tobacco-related cancers (e.g., lung, colorectal, and bladder) and African-American ancestry (13.5%). Tumors were sequenced to identify mutations to gain insight into genetic alterations associated with smoking and/or African-American ancestry. Results: Tobacco-related cancers exhibit a high mutational load. These tumors are characterized by high-frequency mutations in TP53, DNA damage repair genes (BRCA2 and ATM), and chromatin remodeling genes (the lysine methyltransferases KMT2D or MLL2, and KMT2C or MLL3). These tobacco-related cancers also exhibit augmented tumor heterogeneities. Smoking related genetic mutations were validated by The Cancer Genome Atlas dataset that includes 2,821 cases with known smoking status. The Wake Forest and The Cancer Genome Atlas cohorts (431 and 7,991 cases, respectively) revealed a significantly increased mutation rate in the TP53 gene in the African-American subgroup studied. Both cohorts also revealed 5 genes (e.g. CDK8) significantly amplified in the African-American population. Conclusions: These results provide strong evidence that tobacco is a major cause of genomic instability and heterogeneity in cancer. TP53 mutations and key oncogene amplifications emerge as key factors contributing to cancer outcome disparities among different racial/ethnic groups.

Circulating mutational portrait of cancer: manifestation of aggressive clonal events in both early and late stages

BACKGROUND

Solid tumors residing in tissues and organs leave footprints in circulation through circulating tumor cells (CTCs) and circulating tumor DNAs (ctDNA). Characterization of the ctDNA portraits and comparison with tumor DNA mutational portraits may reveal clinically actionable information on solid tumors that is traditionally achieved through more invasive approaches.

METHODS

We isolated ctDNAs from plasma of patients of 103 lung cancer and 74 other solid tumors of different tissue origins. Deep sequencing using the Guardant360 test was performed to identify mutations in 73 clinically actionable genes, and the results were associated with clinical characteristics of the patient. The mutation profiles of 37 lung cancer cases with paired ctDNA and tumor genomic DNA sequencing were used to evaluate clonal representation of tumor in circulation. Five lung cancer cases with longitudinal ctDNA sampling were monitored for cancer progression or response to treatments.

RESULTS

Mutations in TP53, EGFR, and KRAS genes are most prevalent in our cohort. Mutation rates of ctDNA are similar in early (I and II) and late stage (III and IV) cancers. Mutation in DNA repair genes BRCA1, BRCA2, and ATM are found in 18.1% (32/177) of cases. Patients with higher mutation rates had significantly higher mortality rates. Lung cancer of never smokers exhibited significantly higher ctDNA mutation rates as well as higher EGFR and ERBB2 mutations than ever smokers. Comparative analysis of ctDNA and tumor DNA mutation data from the same patients showed that key driver mutations could be detected in plasma even when they were present at a minor clonal population in the tumor. Mutations of key genes found in the tumor tissue could remain in circulation even after frontline radiotherapy and chemotherapy suggesting these mutations represented resistance mechanisms. Longitudinal sampling of five lung cancer cases showed distinct changes in ctDNA mutation portraits that are consistent with cancer progression or response to EGFR drug treatment.

CONCLUSIONS

This study demonstrates that ctDNA mutation rates in the key tumor-associated genes are clinical parameters relevant to smoking status and mortality. Mutations in ctDNA may serve as an early detection tool for cancer. This study quantitatively confirms the hypothesis that ctDNAs in circulation is the result of dissemination of aggressive tumor clones and survival of resistant clones. This study supports the use of ctDNA profiling as a less-invasive approach to monitor cancer progression and selection of appropriate drugs during cancer evolution.

Incidence and clinical significance of ESR1 mutations in heavily pretreated metastatic breast cancer patients

Background

ESR1 mutation has recently emerged as one of the important mechanisms involved in endocrine resistance. The incidence and clinical implication of ESR1 mutation has not been well evaluated in heavily pretreated breast cancer patients.

Methods

We conducted a retrospective review of advanced breast cancer patients with tumors who underwent next-generation sequencing genomic profiling using Foundation One test at Cancer Treatment Centers of America^® regional hospitals between November 2012 and November 2014.

Results

We identified a total of 341 patients including 217 (59%) estrogen receptor (ER)+, 177 (48%) progesterone receptor (PR)+, 30 (8%) hormone receptor+/HER2 positive, and 119 (32%) triple negative patients. ESR1 mutation was noted in 27/222 (12.1%) ER+ or PR+ breast cancer patients. All ER+ patients received at least one line of an aromatase inhibitor. All 28 patients were found to harbor ESR1 mutations affecting ligand-binding domain with the most common mutations affecting Y537 (17/28, 60.7%) and D538 (9/28, 32.1%). In this cohort, 19 (67.9%) patients carried three or more, seven (25%) patients had one or two additional genomic alterations and one (3.6%) patient had an ESR1 mutation only. Of 28 patients, three patients were treated with fulvestrant immediately before and two patients were treated after next-generation sequencing testing; only one patient achieved stable disease for 8 months and the other four patients had progression of disease. In all, 3/3 (100%) patients before testing and 2/4 (50%) after testing treated with exemestane and everolimus achieved stable disease for at least 6 months.

Conclusion

ESR1 mutation was found in 12.1% of a large cohort of advanced breast cancer patients. Exemestane in combination with everolimus might be a reasonable option. Prospective studies are warranted to validate these findings.

Prognostic value of changes in quality of life scores in prostate cancer

Background

Several studies in the oncology literature have demonstrated the prognostic value of baseline quality of life (QoL). We investigated whether changes in QoL could predict survival in prostate cancer patients.

Methods

We evaluated 250 prostate cancer patients treated at our institution between Jan 2001 and Dec 2009 who were available for a minimum follow-up of 3 months. QoL was evaluated at baseline and after 3 months of treatment initiation using EORTC-QLQ-C30. Cox regression evaluated the prognostic significance of baseline and changes in QoL scores after adjusting for relevant clinical and demographic variables.

Results

Median overall survival was 89.1 months (95% CI: 56.5-121.7). Baseline QoL scale predictive of survival upon multivariate analysis was fatigue (p = 0.001). Associations between changes in QoL and survival, upon multivariate analysis, were observed for dyspnea and cognitive functioning. Every 10-point increase (worsening) in dyspnea was associated with a 16% increased risk of death (HR = 1.16; 95% CI = 1.02 to 1.30, p = 0.02), and every 10-point increase (improvement) in cognitive functioning was associated with a 24% decreased risk of death (HR = 0.76; 95% CI = 0.54 to 0.98, p = 0.04).

Conclusions

This study provides preliminary evidence to indicate that prostate cancer patients with better baseline fatigue and patients whose dyspnea and cognitive functioning improves within 3 months of treatment are at a significantly decreased risk of mortality.

Longitudinal health-related quality of life assessment: implications for prognosis in ovarian cancer

Background

There is no information in the literature on the impact of changes in quality of life (QoL) scores on prognosis in ovarian cancer. We investigated whether changes in QoL during treatment could predict survival in ovarian cancer patients.

Methods

We evaluated 137 ovarian cancer patients treated at our institution between Jan 2001 and Dec 2009 who were available for a minimum follow-up of 3 months. QoL was evaluated at baseline and after 3 months of treatment using EORTC-QLQ-C30. Cox regression evaluated the prognostic significance of baseline and changes in QoL scores after adjusting for clinical and demographic variables.

Results

Associations between changes in QoL and survival were observed for global function, appetite loss and constipation. Every 10-point increase (improvement) in global function from baseline to 3 months was associated with a 10% decreased risk of death (HR=0.90; 95% CI: 0.81 to 0.99, p=0.03). The corresponding HRs for 10-point increase (deterioration) in appetite loss and constipation scales were 1.20 (95% CI: 1.06 to 1.35; p=0.005) and 1.13 (95% CI: 1.02 to 1.24; p=0.02) respectively.

Conclusions

This exploratory study provides evidence that an improvement in appetite, constipation and global health scores during the first 3 months of treatment is significantly associated with improved survival time in ovarian cancer. These findings justify serial, systematic assessment of global health, appetite and constipation in ovarian cancer patients being treated, and suggest that modalities designed to improve these functions may be beneficial clinically.

Effect of naturopathic and nutritional supplement treatment on tumor response, control, and recurrence in patients with prostate cancer treated with radiation therapy

OBJECTIVES

Use of naturopathic and nutritional supplements (NNS) with antioxidant activity is controversial in patients receiving radiation therapy. The effects of concomitant use of NNS with antioxidant activity during radiation therapy for prostate cancer were investigated in terms of clinical tumor responsiveness, kinetics, and durability.

MATERIALS AND METHODS

A retrospective investigation was done of 134 patients treated with curative intent for limited-stage prostate cancer by radiation therapy. Patients self-selected to receive NNS as part of their treatment and maintenance during an extended post-treatment interval of at least 2 years. The outcome measures were the following: prostate-specific antigen (PSA) nadir; ≥24 months post-treatment PSA; time to reach nadir; and time to last follow-up were compared across +NNS and -NNS.

RESULTS

Sixty-nine (69) patients elected to receive NNS while 65 did not. Seventy-seven (77) (+NNS 39, -NNS 38) patients received hormone therapy while 57 (+NNS 30, -NNS 27) did not. In the nonhormone cohort, median pretreatment PSA, nadir, post-treatment PSA, time to reach nadir, and time to follow-up were 5.5 ng/mL, 0.56 ng/mL, 0.61 ng/mL, 25 months, and 39.7 months for the -NNS group and 5.1 ng/mL, 0.32 ng/mL, 0.44 ng/mL, 27 months, and 50.1 months for the +NNS group, respectively (p>0.05 for all). Similarly, no significant differences were observed between +NNS and -NNS in the hormone-receiving cohort.

CONCLUSIONS

The clinical tumor response to radiation therapy in patients with limited-stage prostate cancer is not inhibited by concomitant NNS based on the magnitude of the PSA response, the velocity of the PSA nadir, and the duration of PSA normalization.

Abstract 3515: Maitake D-Fraction, a natural mushroom extract, synergizes with Interleukin-2 for increased lytic activity of peripheral blood mononuclear cells against various human tumor cell histologies

Maitake (Grifola frondosa) has been recognized by naturopathic physicians as a medicinal mushroom capable of immune support. Maitake D-Fraction (MDF), a component of the maitake mushroom isolated during hot-water extraction, is rich in α-Glucans and commonly prescribed as a dietary supplement. Because MDF is widely available and easily tolerated, it is highly desirable for the cancer patient looking for immune support via natural products. Previous research has suggested that a dietary MDF regimen can enhance immune function in humans. However, studies to investigate the capacity of MDF to increase tumor immunity are lacking. This study was designed to investigate whether human peripheral blood mononuclear cells (PBMC) treated with MDF develop increased cytolytic capacity against human tumor cells. Cytolysis mediated by MDF-activated PBMC was compared to that of naïve PBMC (media control) and PBMC that were treated with interleukin-2 (IL-2). Immune mediated tumor cytolysis was assessed used a standard Chromium-Release Assay and expressed as number of lytic units (LU)/10^7 effector cells. Target cells for the assays included the PANC1 pancreatic cancer cell line (PA) purchased from ATCC, and single cell suspensions created from peritoneal carcinomatosis (PC) and renal cell carcinoma (RC) tumors resected from patients. Against the PA cells, the LU observed were 16.9 (media control), 12.9 (1ug/ml MDF), 23.8 (10ug/ml MDF) and 28.9 (100ug/ml MDF). The corresponding LU values against PC cells were 7.6, –13.4, –14.2, and –12.1, respectively, and against RC cells 12.3, 2.7, 2.0, and 8.2, respectively. Predictably, PBMC stimulated with an optimally activating dose of IL2 (200U/ml) exhibited a marked increase in LU against all target cells. Nevertheless, when PBMC were stimulated concurrently with both IL-2 and MDF activation was increased further. Thus, LU against PA target cells were 73.0 for PBMC treated with IL-2 alone, and 110.6 for PBMC treated with IL-2 plus 100ug/ml MDF. The corresponding LU values against PC target cells were 37.1 (IL-2 alone), and 66.4 (IL-2 plus 100ug/ml MDF) and against RC target were 94.0 (IL-2 alone) and 110.7 (IL-2 plus 100ug/ml MDF). This study shows that MDF has the capacity to increase the lytic activity produced by an optimally activating dose of IL-2, eliciting greater killing of a variety of human cancer cells than what can be achieved with IL2 alone. It is reasonable to assume that MDF can elicit a similar effect at lower doses of IL-2. Given the toxicity of IL-2 observed in humans, the potential to elicit the desired immune stimulation by combining lower doses of IL-2 with MDF becomes highly desirable. Future clinical trials should be designed to investigate the ability of MDF to elicit optimal immune stimulation with more tolerable doses and schedules of IL-2.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3515. doi:1538-7445.AM2012-3515

Abstract 1552: Resveratrol increases sensitivity of human peritoneal cancer cells to macrophage-mediated cytolysis

The peritoneal cavity contains numerous cells of the immune system capable of mediating antitumor effects. The persistence of cancer in this environment is thought to be due, in part, to the capacity of these cells to circumvent immunologic detection and destruction. Nevertheless, the presence of an immune system within the peritoneal cavity provides the opportunity to elicit tumor cytolysis by resident and/or circulating immune cells mobilized from the peripheral blood. One strategy that may be applicable in this setting is the introduction of compounds into the peritoneal cavity that enhance the sensitivity of malignant cells to activated immune cells. Ideally, these compounds would be tolerated by normal tissues while exerting clinical effects on tumor tissues. In the current investigation, we explored the capacity of the natural product, resveratrol, to modulate sensitivity of human peritoneal cancer cells to the lytic effects of activated human peripheral blood monocytes (PBM). PBM were primed with gamma interferon (IFN) followed by lipopolysaccharide (LPS) as a second signal. Target cells consisted of newly established cells lines from surgical specimens of patients with peritoneal carcinaomatosis (PC) or metastatic colorectal cancer (CRC). Cytolysis was determined following activation with a 24 hour 51Chromium release assay. Control activation of PBM with medium elicted 25 lytic units (LU) and < 5 LU against untreated CRC and PC cells respectively. These values were not changed significantly when resveratrol-pretreated tumor cells were used as targets. In contrast, PBM fully activated with IFN/LPS elicted 224 and 118 LU against untreated CRC and PC respectively and 316 and 199 LU against resveratrol-pretreated CRC and PC respectively. These results were investigated further to determine the effects of resveratrol pretreatment on expression of genes associated with immunologic sensitivity. A real time PCR assay indicated significantly increased expression of death receptors of the TNF superfamily as a consequence of resveratrol pretreatment. Subsequent studies demonstrated that recombinant TNF and TRAIL ligands could significantly inhibit proliferation of resveratrol-pretreated CRC and PC greater than media-pretreated cells. The results of this study demonstrate that human peritoneal cancer cells can be rendered significantly more sensitive to the cytolytic effects of activated human monocytes and macrophages when exposed to the natural product, resveratrol. Given the substantial quantity of macrophages in the peritoneal cavitry of humans, and the influence of malignant tissues on increasing these numbers further, modalities designed to exploit the tumor cytolytic effects of peritoneal macrophages for the treatment of human peritoneal cancers should be explored.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1552. doi:1538-7445.AM2012-1552

The prognostic role of quality of life assessment in breast cancer

While the use of quality of life (QoL) assessments has been increasing in oncology, few studies have examined the prognostic significance of QoL in breast cancer. We investigated the association between QoL at presentation and survival in breast cancer. We examined 1,511 breast cancer patients treated at two single-system cancer centers between January 2001 and December 2008. QoL was evaluated using the validated survey instrument EORTC-QLQ-C30. Patient survival was defined as the time interval between the date of first patient visit and the date of death from any cause/date of last contact. Univariate and multivariate Cox regression analyses were performed to evaluate the prognostic significance of QoL after controlling for the effects of age, tumor stage, and prior treatment history. Mean age at presentation was 52.5 years. There were 590 analytic and 921 non-analytic patients. Patient stage of disease at diagnosis was I, 335; II, 591; III, 290; IV, 159; and 136 indeterminate. Median overall survival was 32.8 months (95% CI: 27.6-38.0). On univariate analysis, QoL function and symptom scales that were predictive of survival were physical (p < 0.001), role (p < 0.001), cognitive (p = 0.003), social (p < 0.001), fatigue (p < 0.001), nausea/vomiting (p < 0.001), pain (p < 0.001), dyspnea (p < 0.001), loss of appetite (p < 0.001), and constipation (p < 0.001). On multivariate analyses, only role function (degree of impairment of work and/or leisure/hobby related activities) was significantly associated with survival. This study suggests that baseline QoL (in particular, the role function) provides useful prognostic information in breast cancer.

Quality of life assessment as a predictor of survival in non-small cell lung cancer

BACKGROUND

There are conflicting and inconsistent results in the literature on the prognostic role of quality of life (QoL) in cancer. We investigated whether QoL at admission could predict survival in lung cancer patients.

METHODS

The study population consisted of 1194 non-small cell lung cancer patients treated at our institution between Jan 2001 and Dec 2008. QoL was evaluated using EORTC-QLQ-C30 prior to initiation of treatment. Patient survival was defined as the time interval between the date of first patient visit and the date of death from any cause/date of last contact. Univariate and multivariate Cox regression evaluated the prognostic significance of QoL.

RESULTS

Mean age at presentation was 58.3 years. There were 605 newly diagnosed and 589 previously treated patients; 601 males and 593 females. Stage of disease at diagnosis was I, 100; II, 63; III, 348; IV, 656; and 27 indeterminate. Upon multivariate analyses, global QoL as well as physical function predicted patient survival in the entire study population. Every 10-point increase in physical function was associated with a 10% increase in survival (95% CI = 6% to 14%, p < 0.001). Similarly, every 10-point increase in global QoL was associated with a 9% increase in survival (95% CI = 6% to 11%, p < 0.001). Furthermore, physical function, nausea/vomiting, insomnia, and diarrhea (p < 0.05 for all) in newly diagnosed patients, but only physical function (p < 0.001) in previously treated patients were predictive of survival.

CONCLUSIONS

Baseline global QoL and physical function provide useful prognostic information in non-small cell lung cancer patients.

Can changes in health related quality of life scores predict survival in stages III and IV colorectal cancer?

Background

Several studies have demonstrated the predictive significance on survival of baseline quality of life (QoL) in colorectal cancer (CRC) with little information on the impact of changes in QoL scores on prognosis in CRC. We investigated whether changes in QoL during treatment could predict survival in CRC.

Methods

We evaluated 396 stages III-IV CRC patients available for a minimum follow-up of 3 months. QoL was evaluated at baseline and after 3 months of treatment using EORTC QLQ-C30. Cox regression evaluated the prognostic significance of baseline, 3-month and changes in QoL scores after adjusting for age, gender and stage at diagnosis.

Results

After adjusting for covariates, every 10-point increase in both baseline appetite loss and global QoL score was associated with a 7% increased risk of death with HR = 1.07 (95% CI, 1.01-1.14; P = 0.02) and (HR = 0.93 (95% CI, 0.87-0.98; P = 0.01) respectively. A lower risk of death was associated with a 10-point improvement in physical function at 3 months (HR, 0.86; 95% CI, 0.78-0.94; P = 0.001). Surprisingly, a higher risk of death was associated with a 10-point improvement in social function at 3 months (HR, 1.08; 95% CI, 1.02-1.13; P = 0.008).

Conclusions

This study provides preliminary evidence to indicate that CRC patients whose physical function improves within 3 months of treatment have a significantly increased probability of survival. These findings should be used in clinical practice to systematically address QoL-related problems of CRC patients throughout their treatment course.

Predicting survival in prostate cancer: the role of quality of life assessment

Purpose

While the use of quality of life (QoL) assessment has been increasing in clinical oncology, few studies have examined its prognostic significance in prostate cancer. We investigated the association between QoL at presentation and survival in prostate cancer.

Methods

We retrospectively reviewed 673 patients treated at two single-system cancer centers between January 2001 and December 2008. QoL was evaluated using EORTC-QLQ-C30. Patient survival was defined as the time interval between the date of first patient visit and the date of death/date of last contact. Univariate and multivariate Cox regression was performed to evaluate the prognostic significance of QoL.

Results

Mean age at presentation was 63.2 years. Patient stage of disease at diagnosis was I, 4; II, 464; III, 76; IV, 107; and 22 indeterminate. Median overall survival was 89.1 months (95% CI: 46.1–132.0). QoL scales predictive of survival upon univariate analysis were physical, role, emotional, social, fatigue, nausea/vomiting, pain, dyspnea, insomnia, loss of appetite, and constipation (p < 0.01 for all). Multivariate analyses found fatigue (p = 0.02) and constipation (p = 0.01) to be significantly associated with survival.

Conclusions

Baseline QoL provides useful prognostic information in prostate cancer. These findings have important implications for patient stratification in clinical trials and may aid decision making in clinical practice.

Abstract 1802: Genomic changes elicited by mitomycin C that confer increased sensitivity of peritoneal cancer cells to death ligands

Mitomycin C (MMC) can be administered by hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of advanced peritoneal cancers (PC) following de-bulking surgery. This strategy produces superior tumor control compared to surgery alone. Nevertheless, most patients relapse within 2 years justifying the need for additional treatment modalities. We have investigated the effects of MMC on the expression of genes that control tumor sensitivity to apoptosis and antitumor immunity and the consequences on in vitro proliferation of PC cells in the presence of different immunologic death ligands. PC cells included the T84 ATCC established cell line, as well as single cell suspensions from surgical specimens of patients with metastatic colon cancer involving the ovary, the stomach and 1 patient with peritoneal carcinomatosis of unknown origin. Tumor genomic expression was assessed by real time PCR and tumor proliferation by the MTS assay. MMC treatment produced a dose-dependent inhibition of proliferation of the T84 cell line ranging from -0.1% (5ng/mL) through 76.5% (250ng/mL). Dose dependent inhibition of proliferation was also observed with cells from human colon cancer specimens with inhibition ranging from 0.3% (5ng/mL) to as much as 83.6% (250ng/mL). A sublethal, pharmacologically-achievable concentration of MMC (25ng/mL) consistently caused significantly increased (2.5-7.5 fold compared to media) expression of various pro-apoptotic genes including: Bax; BIK; DAP Kinase 1; GADD45A; as well as increased (3.3-6.3 fold) expression of caspase-related genes including: CARD6 and caspases 1, 8 and 10. MMC treated cells were also found consistently to express significantly increased (2.3-7.7 fold) levels of FAS and TNF-related death receptors. Notably, the same concentration of MMC either inhibited or did not change the expression of anti-apoptotic genes and did not change expression of potential inhibitors of immunologic lysis such as FAS ligand. These genomic results suggested that there could be additive inhibitory effects of MMC with selected death ligands on the proliferation of PC cells. In fact, the combination of MMC + rTNF inhibited proliferation by 67% compared with 28% and 44% for MMC and rTNF alone respectively. Similar results were obtained with the combination of MMC + rTRAIL (PC cell inhibition = 83% for MMC + rTRAIL vs 28% and 61% for MMC and rTRAIL alone respectively). This study demonstrates that MMC, a standard HIPEC agent employed for the control of residual intraperitoneal tumor following de-bulking surgery, elicits genomic and functional changes that render human PC cells more sensitive to the inhibitory effects of the death ligands, TNF and TRAIL. The results provide a rationale for treatment modalities that stimulate antitumor immunity and the production of immunologic death ligands in the peritoneal cavity of PC patients following HIPEC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1802. doi:10.1158/1538-7445.AM2011-1802

Abstract 4763: Resveratrol synergizes with recombinant death ligands for potent antitumor activity against human metastatic colon cancers

Despite recent advances in the treatment of metastatic colon cancer (CC), most patients are not curable. Furthermore, whenever patients have exhausted all available standard chemotherapy and biologic agent treatment, patients are left with a very poor performance status. Thus, additional therapy for CC needs to be both active against the most advanced forms of the disease and tolerable for patients. Resveratrol (RV) is a phytoalexin from the skin of grapes that has been shown to have inhibitory effects on the proliferation of human tumors. It can be administered to cancer patients as an oral naturopathic/nutritional supplement. The current study investigated the capacity of RV to modulate apoptotic and immunoregulatory gene expression in CC cells and explored the functional consequences of modulation on in vitro tumor cell proliferation. Gene expression was assessed with a real time PCR assay and in vitro proliferation with a standard MTS assay. The ATCC cell line, T84 as well as cell suspensions prepared from metastatic CC specimens involving the stomach (SM), ovary (OM), and extensive peritoneal carcinomatosis (PC) were tested. Inhibition of proliferation was observed with RV alone in concentrations up to 5 ug/mL and this was enhanced further when RV was combined with the immunologic death ligands, rTNF and rTRAIL. For the T84 cell line, levels of proliferation inhibition were 28.0%, 0.5%, 5.4%, 44.5% and 51.8% with RV, TNF, TRAIL, RV+TNF, and RV+TRAIL respectively. The corresponding values for surgical specimens were SM: 5.6%, 1.0%, 0.3%, 28.3%, and 52.4% respectively; OM: 26.2%, 4.6%, 6.1%, 57.4%, and 75.0% respectively; and PC: 46.9%, 17.1%, 59.6%, 61.8% and 96.7%, respectively. These effects of RV + immunologic death ligands were reflected by changes in expression of apoptotic and immunoregulatory genes. For example, in OM cells some of the genes whose expression was up-regulated by RV, TRAIL, and RV+TRAIL were FAS (4.33, 1.57, & 6.22-fold, respectively), DAPK (3.07, 1.16, 3.68), CARD6 (1.96, -1.09, 3.01), and TRADD (2.05, 1.29, 2.31). Consistently, there was increased gene expression in response to the combination of RV +TNF/TRAIL to levels greater than those elicited by any single agent for the following genes: TNFRSF9; CASP10; BCL2L1; BAK1; and BAX. The results of this study demonstrate that RV, a well tolerated oral naturopathic/nutritional supplement can inhibit the in vitro proliferation of human CC cells and collaborate with the immunologic death ligands TNF and TRAIL to inhibit proliferation further. These effects are correlated with changes in expression of apoptotic and immunoregulatory genes in CC cells. Taken together, the results suggest that RV could be combined with cytokine-based therapy or other forms of immunotherapy which elicit immunologic death ligands for the treatment of metastatic CC in patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4763. doi:10.1158/1538-7445.AM2011-4763

Abstract 5610: Epigallocatechin 3-gallate (EGCG) as a natural product (NP) with potent antitumor activity against human ovarian cancer

A substantial challenge in the practice of integrative cancer treatment is to identify active combinations of natural products (NPs) that can collaborate with conventional treatment modalities to achieve enhanced tumor control. This approach is especially attractive for tumors that are inherently chemoresistant or become chemoresistant as a consequence of multidrug resistance. But it has been difficult to prove efficacy of combining NPs with conventional treatment such as chemotherapy due in large part to the challenges inherent in conducting controlled clinical trials with combination regimens. These challenges provide a rationale for translational research studies to characterize effects of NPs on tumor processes relevant to chemoresistance. The current study investigated the activity of Epigallocatechin 3-gallate (EGCG), the principal polyphenol from green tea extract to modulate tumor proliferation and sensitivity to antitumor immunity in human ovarian cancer cells. Tumor proliferation was assessed with a standard MTS assay using the ATCC cell line, OvCar 3 as well as single cell suspensions prepared from human ovarian cancer surgical specimens. Sensitivity to IL2-activated human lymphocytes was assessed with a standard, 4 hr 51Chromium-release assay. EGCG produced a dose-dependent inhhibition of proliferation of the OvCar 3 cell line ranging from &lt;5% (10 ug/mL) through 33% (30 ug/mL). Notably, these concentrations of EGCG are all achievable pharmacologically with a dose of 8, 200 mg capsules daily. Dose dependent inhibition of proliferation was also observed with cells from human ovarian cancer specimens with inhhibition ranging from 10.5% (5 ug/mL) to as much as 54% (25 ug/mL). The effects of EGCG were found to collaborate with pharmacologically achievable concentrations of both cisplatinum (Pt; 500 ng/mL) and gemcitabine (Gz; 10 ng/mL). Thus, 24%, 21% and 60% inhibition of OvCar 3 cells was observed with Pt, EGCG and Pt+EGCG respectively. The corresponding values were 30%, 34%, and 50% inhibition for Gz, EGCG, and Gz+EGCG. Additional effects of EGCG on OvCar 3 were shown in studies using EGCG pre-treatment of target cells prior to testing sensitivity to lysis by IL2-activated human lymphocytes. The results showed that EGCG pretreatment, in doses that did not reduce cell number or inhibit prolliferation over 72 hrs rendered the cells 53% more sensitive to lysis in the 51Chromium-release assay. These results demonstrate direct effects of the principal polyphenol of green tea extract on both the proliferative and immunologic sensitivitiy of human ovarian cancer cells. That these effects can collaborate with chemotherapeutic agents commonly used in the treatment of ovarian cancer patients suggests that combination regimens of this NP with cancer chemotherapy may be valuable in patients for both adjuvant therapy and for maintenance of remission.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5610.

Abstract 5609: Resveratrol as a modulator of human tumor proliferation and immunologic sensitivity

Integrative cancer treatment employing natural products (NPs) in conjunction with conventional therapeutic modalities (Tx) is attractive for tumors that are difficult to control clinically. In this context, pluripotent activities of NPs have the potential of affecting multiple processes relevant to cancer growth. Unfortunately, there is little empiric evidence to elucidate clinically useful effects of NPs making it difficult to optimize Tx regimens. This challenge justifies translational studies to characterize NP effects on processes relevant to tumor control. In the current study, we assessed the action of Resveratrol (RV), a phytoalexin present in the skin of red grapes on the sensitivity of human tumors to proliferation inhibition and antitumor immunity. Proliferation was assessed with MTS assay; immune-mediated lysis with 51Chromium release assay; and gene expression with real time PCR. Using the following ATCC cell lines: malignant melanoma (MM); renal (RC); ovarian (OC); non-small cell lung (NSCLC); pancreatic (PC); breast (BC); and bladder (BLC) cancer, significant dose-dependent proliferation inhibition (paired, 2-tail t tests) in RV-treated cells was demonstrated for all tumors with rank order of sensitivity being: MM &gt; RC &gt; OC &gt; NSCLC &gt; BC &gt; BLC &gt; PC. Significant inhibition (p &lt; 0.05) was also observed with tumor cells from surgical specimens from patients with colon, RC, PC, and OC. The substantial proliferation inhibitory effects of RV on MM (&gt; 80% at 10μg/mL; p = 0.005) and RC (&gt; 65% at 10μg/mL; p = 0.02) was associated with significant chanages in quantitative expression of various pro and anti-apoptotic regulatory genes. For example, RV-treated MM showed &gt; 8 fold down-regulation of anti-apoptotic BCL2 in association with &gt; 13 fold increase in the death associated kinase, DPK1 and RV-treated RC showed 2-3 fold up-regulation of caspases 1, 5, 7, 10, and 14. Moreover, these studies also revealed significantly increased (2-4 fold) expression of different TNF and TRAIL-related death receptors in RV-treated RC and MM cells. Subsequently, testing the effects of RV-pretreated RC and MM to different forms of antitumor immunity showed: 1)RV pre-treated RC are significantly more sensitive to lysis by IL2-activated human lymphocytes compared to control cells (270 vs 121 lytic units respectively, p=0.04); and, 2) proliferation of MM is inhibited significantly (p&lt;0.05) in an additive fashion by the combination of RV + rTNF or RV + rTRAIL. This study demonstrates that RV can favorably modulate tumor cell proliferation and sensitivity to tumor immune mechanisms in some of the most difficult to treat human cancer histologies. These sorts of studies should facilitate development of integrative treatment modalities to exploit the pluripotent activities of NPs such as RV in specific oncologic settings.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5609.

Optimizing innovation in health care organizations

There are many steps to consider when making the move to become an innovative health care organization. Take a look at the people and processes to have in place.

Percutaneous radiofrequency-assisted excision of fibroadenomas

INTRODUCTION

Fibroadenomas are a frequently encountered benign tumor that will occur in approximately 10% of women during their lifetime. Although the natural history would suggest fibroadenomas diagnosed with minimally invasive needle core biopsy can be safely observed, the majority are still surgically removed in the operating room. In an effort to limit the more than 500,000 surgical fibroadenoma removals performed each year, percutaneous excision has become a viable alternative. Percutaneous excision of intact fibroadenomas versus removal with a multiple core sampling technique has the dual potential advantage of causing minimal intervention combined with provision of adequate sample for thorough histopathology and margin analysis for confirmation of complete removal. An 18-month retrospective analysis was undertaken to evaluate the utilization of a new radiofrequency-assisted biopsy device in the successful removal and continued absence of histologically confirmed fibroadenomas on 4- to 6-month follow-up imaging.

METHODS

Between April 2004 and November 2005, 100 patients underwent ultrasound- or stereotactic-guided, radiofrequency-assisted intact percutaneous excision of 106 diagnosed fibroadenomas of the breast. Patients were comprised of 100 women whose ages ranged from 18-70 years (median age, 45 years).

RESULTS

Indications for the procedure included palpable mass, 77; abnormal mammogram, 13; and abnormal ultrasound, 10, as the patient's initial presentation. Ultrasound was used to guide the procedure in 82 patients, and stereotactic was used in 18 patients. One early study procedure was performed under general anesthesia; the remaining studies were performed under local anesthesia (1% lidocaine) using from 10 to 45 mL. On pathologic examination, the tumors ranged in size from 6 to 27 mm (mean diameter, 14 mm) and weighed from 0.6 to 2.0 g (mean weight, 1.0 g). Patients reported minimum discomfort related to the procedure; pain scores ranged from 0 to 10 (mean pain score, <1). Complications were minimal, with only 2 patients having bleeding, which was controlled by conservative measures. At the 4- to 6-month follow-up, 79 of 85 (93%) evaluable patients showed no physical or imaging evidence of residual fibroadenoma, an additional 5 patients have reported no physical findings or further complaints and have required no further need for medical evaluation, 8 have been lost to follow-up, and 2 have yet to be reevaluated.

CONCLUSIONS

Percutaneous ultrasound- or stereotactic-guided, radiofrequency-assisted excision of fibroadenomas of the breast may be performed in an ambulatory setting under local anesthesia. The procedure provides intact specimens that in most cases appear to be completely removed after follow-up of 4 to 6 months. The procedure is well tolerated by patients and is associated with minimal complications.

An evaluation of the American College of Surgeons' ultrasound education program

BACKGROUND

Ultrasound has a wide variety of applications in surgery, but until recently few surgeons received any formal training in its use. To facilitate incorporation of ultrasound into surgical practice, the American College of Surgeons (ACoS) developed an ultrasound educational program. The purpose of this study was to evaluate the impact and effectiveness of the ACoS ultrasound education program.

METHODS

A survey was mailed to all surgeons who had completed at least one of several ultrasound courses offered by the ACoS from 1998 to 2002.

RESULTS

A total of 1,791 surveys were mailed out and 873 completed surveys were returned. Sixty-five percent (576) of respondents reported using ultrasound in their practices after these educational courses. Of those performing ultrasound examinations, 267 did so in one clinical area and 309 in more than one. The most common examination was breast (369 surgeons); vascular, acute/trauma, abdominal, intraoperative/laparoscopic, and head/neck were utilized fairly equally (100-200 surgeons). The number of examinations performed by surgeons before they felt competent was between 11 and 20 and did not vary by the type of ultrasound examination. Of the 267 surgeons performing ultrasound in one clinical area, 176 performed ultrasound-guided procedures. Most surgeons had access to 2 ultrasound machines, but 386 (67%) were restricted from performing ultrasound in certain locations.

CONCLUSIONS

The ACoS ultrasound courses are extremely popular and have contributed to the increasing use of ultrasound in surgical practice. Surgeons successfully use ultrasound in their practices including performance of ultrasound-guided procedures but are restricted from using ultrasound in certain patient care areas. Since many surgeons received prior and/or additional training outside of the ACoS, there is a need to facilitate export of ACoS courses to other venues and to focus on incorporating ultrasound training into surgical residency programs.

An evaluation of the American College of Surgeons’ ultrasound education program

BACKGROUND

Ultrasound has a wide variety of applications in surgery, but until recently few surgeons received any formal training in its use. To facilitate incorporation of ultrasound into surgical practice, the American College of Surgeons (ACoS) developed an ultrasound educational program. The purpose of this study was to evaluate the impact and effectiveness of the ACoS ultrasound education program.

METHODS

A survey was mailed to all surgeons who had completed at least one of several ultrasound courses offered by the ACoS from 1998 to 2002.

RESULTS

A total of 1,791 surveys were mailed out and 873 completed surveys were returned. Sixty-five percent (576) of respondents reported using ultrasound in their practices after these educational courses. Of those performing ultrasound examinations, 267 did so in one clinical area and 309 in more than one. The most common examination was breast (369 surgeons); vascular, acute/trauma, abdominal, intraoperative/laparoscopic, and head/neck were utilized fairly equally (100-200 surgeons). The number of examinations performed by surgeons before they felt competent was between 11 and 20 and did not vary by the type of ultrasound examination. Of the 267 surgeons performing ultrasound in one clinical area, 176 performed ultrasound-guided procedures. Most surgeons had access to 2 ultrasound machines, but 386 (67%) were restricted from performing ultrasound in certain locations.

CONCLUSIONS

The ACoS ultrasound courses are extremely popular and have contributed to the increasing use of ultrasound in surgical practice. Surgeons successfully use ultrasound in their practices including performance of ultrasound-guided procedures but are restricted from using ultrasound in certain patient care areas. Since many surgeons received prior and/or additional training outside of the ACoS, there is a need to facilitate export of ACoS courses to other venues and to focus on incorporating ultrasound training into surgical residency programs.

Aromatase inhibitors increase the sensitivity of human tumor cells to monocyte-mediated, antibody-dependent cellular cytotoxicity

OBJECTIVE

A randomized, placebo-controlled phase III trial of the breast cancer vaccine Theratope (Biomira Corporation, Edmonton, Alberta, Canada), which expresses the underglycosylated, mucin-associated peptide STn showed that patients treated concomitantly with hormone therapy plus vaccine survived significantly longer than patients treated with hormone therapy plus a control vaccine. The objective of this study was to elucidate a mechanism to explain this effect.

METHODS

Tumor cells characterized for expression of estrogen receptor (ER), STn, and Mucin-1 (Muc1) were pretreated (24 hours) with the aromatase inhibitor (AI) formestane, followed by assessment of sensitivity to monocyte-mediated killing in the presence and absence of STn or Muc1 antibodies (Abs) using the (51)Cr-release assay.

RESULTS

ER+/STn+/Muc1+ tumor cells cultured in medium were equally sensitive to killing by monocytes in the absence or presence of STn and Muc1 Abs (mean = 54% and 55% cytolysis, respectively, P = not significant). Formestane-pretreated cells showed decreased sensitivity to killing by monocytes in the absence of Abs (mean = 45% cytolysis, P = .07) but significantly increased sensitivity to monocyte-mediated, antibody-dependent cellular cytotoxicity (MM-ADCC) (mean = 65%, P = .003). These effects were not seen with either ER+/STn-/Muc1+ cells or ER-/STn+/Muc1+ cells, indicating the need for both ER and STn positivity of the target tumor cells.

CONCLUSIONS

Tumor cells treated with an AI exhibit increased sensitivity to MM-ADCC. The capacity of an AI to "sensitize" tumor cells to this form of antitumor immunity represents a heretofore, undescribed mechanism whereby a hormone-based treatment may collaborate with antigen-specific tumor immunity to produce improved tumor control in vivo in metastatic breast cancer patients.

Use of intraoperative ultrasound in excision of multiple schwannomas of the thigh

Schwannomatosis is a rare neoplastic condition of unclear etiology characterized by multiple schwannomas in the absence of other manifestations of neurofibromatosis. In very rare cases, these tumors develop in an isolated region of the body. Complete removal of these tumors presents a surgical challenge because they are often small and difficult to locate. We found that intraoperative sonography offers invaluable assistance in such cases by localizing small schwannomas and decreasing operative time and extent of the surgical dissection.

Updates in breast ultrasound

Ultrasound is becoming an indispensable tool for the surgeon in the diagnosis and treatment of a variety of breast problems. Hands-on ultrasound education for surgeons and the ongoing improvements in imaging technology have made surgeon-performed breast ultrasound an effective method of identifying and diagnosing breast lesions and have increased the surgeon's ability to perform ultrasound-guided interventional procedures. This article reviews the current state of surgeon-performed breast ultrasound.

Hormone replacement therapy in postmenopausal women

BACKGROUND

For many years, hormone replacement therapy (HRT) was considered an effective method of restoring the relative protection from coronary artery disease enjoyed by premenopausal women compared with men of similar age. This view has been supported by a substantial number of basic science and observational studies.

DATA SOURCES

Results of recent randomized controlled trials have seriously challenged the concept of the protective value of HRT by showing that rather than decreasing the risk of coronary artery disease, HRT actually appears to increase it. In addition, it increases the risk for breast cancer, stroke, venous thromboembolism, and cholecystitis.

RESULTS

Despite some benefits such as increased bone mineral density and decreased risk of fracture and colorectal cancer, these data suggest that the risks of HRT outweigh the benefits.

CONCLUSIONS

HRT is no longer routinely recommended for prevention of chronic disease. We present the current scientific data, benefits, risks, and consequent clinical recommendations regarding HRT use in postmenopausal women.

Ultrasound in head and neck surgery: thyroid, parathyroid, and cervical lymph nodes

Ultrasound (US) of the neck is extremely sensitive in detecting thyroid, parathyroid, and cervical lymph node pathology, and is regarded as the most complete and cost-effective imaging method for evaluating the thyroid and parathyroid glands, as well as for the diagnostic evaluation of the cervical lymph node basin. US is widely used in screening high-risk individuals, evaluation of palpable and nonpalpable thyroid nodules, needle guidance for biopsy of nonpalpable and suspicious nodules, and preoperative evaluation of the extent of thyroid neoplasms, as well as in the detection of residual, recurrent, or metastatic thyroid tumors, and in observing nonsurgical cases. It has thus become an important adjunct to the practice of head and neck surgery.

Surgery residents' perception of the Objective Structured Clinical Examination (OSCE)

PURPOSE

Beginning in July 2003, residency programs will be required to incorporate new educational assessment methods as defined by the Accreditation Council for Graduate Medical Education (ACGME) outcome initiative. The Objective Structured Clinical Examination (OSCE) is an assessment tool that is favorably viewed by the ACGME. Our institution has utilized the OSCE for evaluation of surgery trainees since 1996. Despite the positive acceptance of the OSCE by students, residents expressed dissatisfaction with the examination. This study was therefore undertaken to specifically evaluate resident perception of the OSCE.

METHODS

Two sequential surveys were administered to surgery residents at the Medical College of Ohio. Response of medical students to a standard survey following completion of the OSCE was tabulated.

RESULTS

On the first, general survey, residents felt that the OSCE was not an adequate measure of either clinical (15 of 17 residents) or technical (15 of 18 residents) skills; 14 of 16 residents felt that the OSCE should not be used when considering promotion. When specifically queried in a follow-up survey, residents indicated that the OSCE was an adequate measure of clinical knowledge (2.2 +/- 0.3); however, most still felt that the OSCE should not be used when considering promotion (4.3 +/- 0.3). (Scores = mean +/- SEM on a Likert scale where 1 = strongly agree and 5 = strongly disagree). By contrast, 97.6% of 663 medical students surveyed (September 1996 through February 2002) felt the OSCE was useful.

CONCLUSIONS

The OSCE has been shown to be a reliable and valid measure of basic clinical and technical competence. Despite our residents' current perception, we believe that the OSCE is an important method for resident evaluation, particularly within the context of the current ACGME outcome initiative.

Granular cell tumor of the breast

Granular cell tumors (GCT) are uncommon, usually benign, neoplasms that are thought to derive from Schwann cells of the peripheral nerves. They can originate anywhere in the body but are most frequently found in the head and neck, particularly in the oral cavity. When they are located in the breast, as may occur in 5-8 per cent of cases, the clinical and pathologic appearance is similar to that of a malignant tumor. Immunohistochemical analysis, including reactivity for periodic acid-Schiff, CD68, and S100 and negative reactivity for cytokeratin, is required for definitive diagnosis. Awareness of this tumor's unique characteristics might aid in differentiating it from the more common malignant tumors of the breast.

Granular Cell Tumor of the Breast

Granular cell tumors (GCT) are uncommon, usually benign, neoplasms that are thought to derive from Schwann cells of the peripheral nerves. They can originate anywhere in the body but are most frequently found in the head and neck, particularly in the oral cavity. When they are located in the breast, as may occur in 5–8 per cent of cases, the clinical and pathologic appearance is similar to that of a malignant tumor. Immunohistochemical analysis, including reactivity for periodic acid–Schiff, CD68, and S100 and negative reactivity for cytokeratin, is required for definitive diagnosis. Awareness of this tumor's unique characteristics might aid in differentiating it from the more common malignant tumors of the breast.

Management of nonpalpable ultrasound-indeterminate breast lesions

BACKGROUND

A series of such lesions was studied to determine the validity of applying criteria routinely used to manage palpable breast cysts to the management of mammographically detected, nonpalpable breast lesions characterized as indeterminate on ultrasound (US).

METHODS

The clinicopathologic data from a series of 134 patients who underwent US-guided fine needle aspiration biopsy for nonpalpable, mammographically detected breast lesions, categorized as indeterminate on US, were reviewed.

RESULTS

Of 139 indeterminate lesions, 78 were consistent with complex cysts, whereas in 61, the cystic-versus-solid nature was indistinguishable. All 71 complex cyst lesions that contained nonbloody fluid and resolved completely were benign. Two of 7 complex cyst lesions that had incomplete resolution, bloody aspirate, or both were malignant. Of 61 cystic-versus-solid lesions, 29 and 32 were primarily solid and cystic, respectively. Three of the 29 solid lesions were malignant. Of the 32 cystic lesions, all 26 that contained nonbloody fluid and resolved completely were benign, whereas 1 of 6 lesions that had incomplete resolution, bloody aspirate, or both was malignant.

CONCLUSION

Criteria such as complete resolution and nonbloody aspirate are an effective adjunct to the management of nonpalpable, mammographically detected breast lesions categorized as indeterminate by US.

Matrix metalloproteinase expression in breast cancer

BACKGROUND

Matrix metalloproteinases (MMPs) have been implicated as possible mediators of invasion and metastasis in some cancers. Our objective was to investigate which MMPs were constitutively expressed in breast tumor cells versus those that could be up-regulated by a number of agents known to affect MMP expression in other cell systems.

METHODS

We evaluated expression of MMPs 1-16 in breast tumor cell lines MDA-MB-231, T47D, and MCF-7 using semiquantitative RT-PCR and gelatin zymography. Exposure to 12-O-tetradecanoylphorbal-3-acetate (TPA), concanavalin-A (Con-A), the fibronectin-mimetic peptide GRGDSP (RGD), extracellular matrix (ECM) components, and anti-integrin antibodies was used to test for possible MMP up-regulation. Mitogen-activated protein kinase inhibitors (MAPK-I) were used to evaluate signal transduction pathways and regulation of MMP expression.

RESULTS

MMPs 1, 2, 7-11, 13, 14, and 16 were constitutively expressed in some tumor cell lines but not in normal breast epithelial cells. Administration of TPA, Con-A, and RGD increased the expression of MMPs 1, 2, 9, and 10. No MMP up-regulation was seen in MDA-MB-231 or MCF-7 after exposure to ECM components or after exposure to anti-integrin antibodies. MAPK-I had no effect on constitutive MMP expression but reduced or abolished the TPA up-regulation of MMP-9 in MDA-MB-231 and MCF-7.

CONCLUSIONS

Breast tumor cell lines constitutively express a number of MMPs. Because MMP expression can be up-regulated by Con-A, the fibronectin-mimetic peptide RGD, and TPA while being susceptible to inhibition by MAPK antagonists, MAPK signaling appears to play a role in this expression.

Adhesion and migration of extracellular matrix-stimulated breast cancer

BACKGROUND

Extracellular matrix (ECM) components, such as vitronectin and fibronectin, have been shown to enhance the metastatic potential of breast cancer cells. We hypothesized that ECM binding to integrin receptors on breast cancer cells influenced cellular adhesion and migration.

MATERIALS AND METHODS

Adhesion assays were performed using breast cancer cell lines MDA-MB-435 and MDA-MB-231 and various concentrations of vitronectin or fibronectin. Migration assays were performed using the same cell lines and invasion chambers with 8 microm pore polycarbonate membranes. Blocking antibodies and specific peptidomimetic inhibitors to integrin receptors were used to identify the integrin subunits reacting with vitronectin and fibronectin.

RESULTS

While both breast cancer cell lines adhered to and migrated toward vitronectin and fibronectin, MDA-MB-435 had a higher maximum binding to vitronectin and MDA-MB-231 had a higher maximum binding to fibronectin. Anti-beta1 antibody inhibited the adhesion and migration of MDA-MB-231 to fibronectin and the adhesion of MDA-MB-231 to vitronectin but had no effect on vitronectin-induced adhesion or migration of MDA-MB-435. The alpha(v)beta3/alpha(v)beta5 antagonist, SB 265123, inhibited MDA-MB-231 and MDA-MB-435 adhesion and migration to vitronectin but had no effect on migration to fibronectin in either cell line.

CONCLUSIONS

We conclude that the integrin subunits beta1, alpha(v)beta3, and alpha(v)beta5 can be involved in breast cancer cell adhesion and migration to vitronectin and fibronectin. Because more than one integrin inhibitor was required to block adhesion or migration in the cell lines studied, breast cancer therapy based on integrin antagonists would most likely require concomitant use of multiple agents.

Ability of the objective structured clinical examination to differentiate surgical residents, medical students, and physician assistant students

BACKGROUND

The Objective Structured Clinical Examination (OSCE) has been used extensively to evaluate the clinical abilities of medical students and residents. The purpose of this study was to investigate whether the standard OSCE would differentiate performance of subjects with different levels and/or types of training.

METHODS

We conducted a blinded OSCE, during which we simultaneously evaluated surgical residents from all 5 years of the general surgery training program, third-year medical students, and second-year physician assistant students. All examinees went through the same clinical evaluation stations, which consisted of history-taking, physical examination, technical skills, trauma management, and X-ray interpretation. The students and residents were rated at each station by a trained standardized patient evaluator or a faculty evaluator using a checklist for performance evaluation. All subjects wore surgical scrubs without name tags or identification of program or year of training.

RESULTS

Overall mean performance scores (P = 0.09, NS) were for surgical residents 71.2% (+/-9.7); for medical students 66.9% (+/-5.7); for physician assistant students 64.7% (+/-5.8). This shows a significant trend toward higher scores with more training. Surgical residents scored higher on technical stations, history-taking, and X-ray interpretation. Medical students scored higher in performance of physical examination. Physician assistant students scored quite close to the other two groups.

CONCLUSIONS

The differences among group performance appeared to reflect the level of experience of the learners. Some components of the OSCE appear to better differentiate levels of training.

Modulation of tumor-infiltrating lymphocyte cytolytic activity against human non-small cell lung cancer

The cytokines expressed in tumor microenvironments are thought to be important mediators of both the host immune response and tumor survival. The source of these cytokines includes tumor cells, infiltrating leukocytes, fibroblasts, and other stromal elements. We previously reported that tumor-infiltrating lymphocytes (TIL) from human non-small cell lung cancer (NSCLC) express predominantly type 1 cytokines, which are known to enhance cell-mediated immunity. The purpose of this study is to assess the cytokine mRNA expression of human NSCLC primary cell lines and the capacity of the tumor-associated cytokines to modulate the development of TIL cytolytic activity against the autologous tumor. Cytokine mRNA expression was determined by RT-PCR and the capacity of TIL to kill autologous lung tumor cells was measured by the chromium-51 (51Cr) release assay. All NSCLC primary cell lines expressed mRNA for IL-4, IL-6, and transforming growth factor-beta1 (TGFbeta1), whereas IL-10 was expressed in only 1/7 cell lines. When added to TIL cultures stimulated with anti-CD3+IL-2, IL-4 and IL-10 enhanced and TGF-beta1 suppressed the development of TIL cytolytic activity against autologous tumor cells. The effects of IL-6 were inconsistent and for the group, were not statistically significant. These results demonstrate that human NSCLC cells express cytokines with the capacity to regulate the in situ anti-tumor immune response. However, the effects of tumor-derived cytokines varied qualitatively and quantitatively suggesting the balance between specific type 2 cytokines or TGF-beta1 within tumor microenvironments may influence prognosis or response to immunotherapy.

Surgical educator preferences regarding key objective structured clinical examination topics

BACKGROUND

Numerous methods are used for assessing the performance of surgical residents and students. Unfortunately, these same methods are often unsatisfactory. One technique that is gaining increased favor is the Objective Structured Clinical Examination (OSCE). It is unclear what areas of evaluation might best be included in such an examination so as to optimize its value. Therefore, this study evaluated the opinions of an international body of surgical educators.

METHODS

A survey was distributed to 674 attending surgical educators; it asked respondents to select and rank the five most important topics from four areas. These areas included 84 topics from History Taking, Physical Examination, Data Interpretation, and Surgical Technique. A weighted score was calculated for each topic by assigning points according to a Likert scale ranking.

RESULTS

Among 674 surveys distributed, 243 responses (36.1%) were received; 25 of the 243 responses were excluded, for a usable response rate of 218/674 (32.3%). The five highest ranked topics were (History Taking) "abdominal pain" 29.2%, "breast mass" 10.8%, "gastrointestinal bleeding" 8.5%, "bowel obstruction" 8.5%, "trauma" 7.2%; (Physical Examination) "acute abdomen" 28.9%, "trauma survey" 18.2%, "breast examination" 15.8%, "peripheral vascular" 8.9%, "cardiopulmonary" 7.5%; (Data Interpretation) "chest X ray" 21%, "abdominal series" 20.2%, "CT scan" 19.6%, "mammogram" 10.1%, "cervical spine films" 5.2%; and (Surgical Technique) "central line" 16.1%, "basic suture skills" 14.2%, "bowel anastomosis" 8.0%, "informed consent" 7.9%, "intubation" 6.4%.

CONCLUSION

This survey offers useful data regarding those skills viewed as most important by experienced surgical educators, and offers guidelines for composition of surgical OSCEs.

Mechanisms of taxotere-related drug resistance in pancreatic carcinoma

BACKGROUND

Pancreatic adenocarcinoma (PAC) is generally refractory to most chemotherapeutic agents, including docetaxel (Taxotere; TXT). Specific mechanisms for TXT-related drug resistance in PAC have not been defined. The hypothesis of this study was that PAC resistance to TXT is primarily related to P-glycoprotein (P-gp), the expression product of multiple drug resistance (MDR)-1, as opposed to lung resistance protein (LRP) or multidrug resistance protein (MRP).

MATERIALS AND METHODS

The sensitivity of the PAC cell line SUIT-2 and its sublines to TXT, doxorubicin (DOX) and 5-fluorouracil (5-FU) was evaluated with a 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide assay. MDR1 (P-gp), MRP, LRP, and beta-tubulin isotype gene expressions were detected at the messenger RNA level by reverse transcription-polymerase chain reaction (RT-PCR). Verapamil and indomethacin (IMC) were used to test the functionality of P-gp and MRP, respectively.

RESULTS

The SUIT-2 subline S-020 and the TXT-selected SUIT-2 cell line S2/TXT were significantly resistant to TXT. Both showed cross-resistance to DOX but no resistance to 5-FU. RT-PCR demonstrated strong expression of P-gp in S-020 and S2/TXT and weaker or no expression in other cells lines. MRP and LRP expression was found in most of these cell lines but had no relationship to the TXT resistance. TXT resistance in S2-020 and S2/TXT could be reversed by verapamil but not by IMC. Levels of beta-tubulin isotype II and III were increased in S2/TXT compared with S-020 and SUIT-2.

CONCLUSIONS

Intrinsic and acquired TXT resistance is primarily mediated by P-gp, but not by MRP or LRP, and is markedly reversed by the P-gp modulator verapamil. Hence future related studies should focus on the use of agents that block the transporter action of P-gp.

Invasiveness and MMP expression in pancreatic carcinoma

BACKGROUND

Previous investigations have suggested that expression of matrix metalloproteinases (MMPs) may be related to increased invasiveness of various tumors. This study evaluated a possible relation between pancreatic tumor cell invasiveness and MMPs.

METHODS

A Matrigel invasion assay was performed with pancreatic tumor cell line SUIT-2 and its sublines S2-007, S2-013, S2-020, and S2-028. The degree of invasiveness of stimulated and unstimulated cell lines was correlated with MMP gene expression measured by RT-PCR and MMP protein product measured by gelatin zymography. Cell lines were stimulated by 12-O-tetradecanoylphorbol-13-acetate (TPA), concanavalin (Con-A), and polymerized collagen type I gel (Vitrogen).

RESULTS

For SUIT-2, S2-007, S2-013, S2-020, and S2-028, 3.2, 1.0, 4.1, 6.4, and 0.4%, respectively, of the cells invaded the Matrigel membrane. TPA, Con-A, and Vitrogen resulted in the up-regulation of MMP-2 in S2-020. TPA and Vitrogen resulted in up-regulation of MMP-9 in each of the cell lines, while Con-A could up-regulate MMP-9 expression only in SUIT-2. There was no constitutive expression of either MMP-2 or MMP-9 in SUIT-2 or its sublines. There was a positive relationship between Matrigel invasiveness and up-regulation of MMP-2 and MMP-9 expression.

CONCLUSION

These data suggest that, while MMP-2 and MMP-9 are not constitutively expressed in pancreatic carcinoma cell lines, they may be up-regulated by TPA, Con-A, and Vitrogen. Since MMP-2 and MMP-9 expression correlated with degree of tumor cell invasiveness, the ability to up-regulate MMP-2 and MMP-9 expression may play a role in facilitating pancreatic tumor cell invasion.

Objective Structured Clinical Examination Technical Skill Stations Correlate More Closely with Postgraduate Year Level than Do Clinical Skill Stations

Validity of an examination format is supported by its ability to distinguish levels of training among examinees. The Objective Structured Clinical Examination (OSCE) is a developing format generally composed of various types of task-oriented stations used to evaluate clinical skills of students and residents. The ideal composition of OSCE stations to maximize validity has not been determined. We examined the relative correlation between selected types of stations and level of resident postgraduate year (PGY). A 12-station OSCE was administered to surgical residents of all PGY levels at a university program. Individual station scores were correlated with PGY level. The overall correlation of the total examination score with PGY level was good (R = 0.681). Technical skill stations exhibited a significantly greater correlation with PGY level (0.679 vs 0.203) as compared with clinical skill stations ( P < 0.05). These data suggest that technical skill evaluation is more sensitive in distinguishing level of training of surgical residents than is clinical skill evaluation.

Objective Structured Clinical Examination technical skill stations correlate more closely with postgraduate year level than do clinical skill stations

Validity of an examination format is supported by its ability to distinguish levels of training among examinees. The Objective Structured Clinical Examination (OSCE) is a developing format generally composed of various types of task-oriented stations used to evaluate clinical skills of students and residents. The ideal composition of OSCE stations to maximize validity has not been determined. We examined the relative correlation between selected types of stations and level of resident postgraduate year (PGY). A 12-station OSCE was administered to surgical residents of all PGY levels at a university program. Individual station scores were correlated with PGY level. The overall correlation of the total examination score with PGY level was good (R = 0.681). Technical skill stations exhibited a significantly greater correlation with PGY level (0.679 vs 0.203) as compared with clinical skill stations (P < 0.05). These data suggest that technical skill evaluation is more sensitive in distinguishing level of training of surgical residents than is clinical skill evaluation.

Diagnostic and interventional ultrasound for breast disease

The availability of reliable, portable computer-enhanced ultrasonography with high-frequency transducers has improved breast ultrasonography such that its role has increased dramatically. Diagnostic characteristics of breast lesions may be used to categorize these lesions according to their relative risk for malignancy. Furthermore, breast ultrasonography may be used to guide needle aspiration and biopsy of lesions so indicated by diagnostic evaluation. Results of ultrasound-guided aspiration and core biopsy accurately diagnose specific histopathology thereby avoiding unnecessary open biopsy for benign lesions and facilitating therapeutic planning for malignant lesions.

Cytokine biosynthesis by tumor-infiltrating T lymphocytes from human non-small-cell lung carcinoma

PURPOSE

The purpose of this work was to assess the capacity of tumor-infiltrating leukocytes (TIL) from human non-small-cell lung carcinoma (NSCLC) specimens to synthesize type-1 and type-2 cytokines.

METHODS

TIL were isolated from tumors following digestion with collagenase/DNase and further enriched by ficoll-hypaque gradient centrifugation. Membrane phenotypes and intracellular cytokine protein expression of TIL were assessed by flow cytometry.

RESULTS

The majority of TIL expressed the CD3 antigen with a CD4:CD8 ratio of approximately 2:1. Other leukocytes such as macrophages (CD14), B lymphocytes (CD20), and natural killer (NK) cells (CD56) were also found to infiltrate the tumors, but in significantly lower numbers. Owing to the limited recovery of non-CD3(+) leukocytes, our analysis of cytokine biosynthesis has focused on T lymphocytes. In the absence of activation, a small percentage of CD3(+) TIL synthesized cytokines ( <4%). Following activation with anti-CD3+interleukin-2 (IL-2), CD3(+) TIL synthesized predominantly a type-1 cytokine profile; however, the type-2 cytokines, IL-6 and IL-10, were also detected in a small percentage of infiltrating cells. Following activation with phorbol 12-myristate 13-acetate + ionomycin, CD3(+) TIL also expressed more type-1 than type-2 cytokines and in significantly greater numbers of cells. The CD3(+)CD8(+) component of the TIL synthesized only type-1 cytokines, whereas the CD3(+)CD4(+) component synthesized both type-1 and type-2 cytokines.

CONCLUSION

These results show that the majority of the TIL isolated from NSCLC specimens are T lymphocytes with the capacity to synthesize type-1 cytokines.