The incidence of hypotension during general anesthesia: a single-center study at a university hospital

BACKGROUND

Although intraoperative hypotension (IOH) has been emerging as a serious concern during general anesthesia, the incidence of IOH has not been demonstrated clearly in the Japanese population.

METHODS

This single-center retrospective study investigated the incidence and the characteristics of IOH in non-cardiac surgery at a university hospital. IOH was defined as at least one fall of MAP during general anesthesia, which was categorized into the following groups: mild (65 to < 75 mmHg), moderate (55 to < 65 mmHg), severe (45 to < 55 mmHg), and very severe (< 45 mmHg). The incidence of IOH was calculated as a percentage of the number of events to the total anesthesia cases. Logistic regression analysis was performed to examine factors affecting IOH.

RESULTS

Eleven thousand two hundred ten cases out of 13,226 adult patients were included in the analysis. We found moderate to very severe hypotension occurred in 86.3% of the patients for at least 1 to 5 min, and 48.5% experienced severe or very severe hypotension. The results of the logistic regression analysis indicated female gender, vascular surgery, American Society of Anesthesiologists physical status classification (ASA-PS) 4 or 5 in emergency surgery, and the combination with the epidural block (EDB) were significant factors of IOH.

CONCLUSIONS

IOH during general anesthesia was very frequent in the Japanese population. Female gender, vascular surgery, ASA-PA 4 or 5 in emergency surgery, and the combination with EDB were independent risk factors associated with IOH. However, the association with patient outcomes were not elucidated.

Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study

PURPOSE

Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits.

METHODS

This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution.

RESULTS

Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009).

CONCLUSION

CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.

Cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic aortic repair

BACKGROUND

Cerebrospinal fluid drainage (CSFD) is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair. Although small studies support the use of CSFD, systematic reviews have not suggested definite conclusion and a large-scale study is needed. Therefore, we reviewed medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open and endovascular repair) at multiple institutions to assess the association between CSFD and postoperative motor deficits.

METHODS

Patients included in this study underwent descending or thoracoabdominal aortic repair between 2000 and 2013 at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery. We conducted a retrospective study to investigate whether motor-evoked potential monitoring is effective in reducing motor deficits in thoracic aortic aneurysm repair. We use the same dataset to examine whether CSFD reduces motor deficits after propensity score matching.

RESULTS

We reviewed data from 1214 patients [open surgery, 601 (49.5%); endovascular repair, 613 (50.5%)]. CSFD was performed in 417 patients and not performed in the remaining 797 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. After propensity score matching (n = 700), mixed-effects logistic regression performed revealed that CSFD is associated with postoperative motor deficits at discharge [adjusted odds ratio (OR), 3.87; 95% confidence interval (CI), 2.30-6.51].

CONCLUSION

CSFD may not be effective for postoperative motor deficits at discharge.

P3534Optimal dosing of initial bolus of intravenous furosemide in acute heart failure: insights from REALITY-AHF

Background

Although intravenous diuretics are a cornerstone in the treatment of patients with acute heart failure (AHF), optimal dosing of initial bolus of IV diuretics has not been well elucidated.

Methods

The initial IV bolus dose of furosemide and its association with outcomes were analyzed in 1290 AHF patients (median age, 81 years, 55% were male) derived from REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure). The patients were divided into 3 groups; lower dose (lower than recommended dose, n=371), standard dose (same as recommended dose, n=807), and higher dose (higher than recommended dose, n=112) groups according to the recommended initial IV bolus furosemide dose derived from the maintenance loop diuretics dose (for those without taking oral loop diuretics or taking ≤40mg/day oral furosemide-equivalent loop diuretics, 20mg IV bolus furosemide; those on >40mg/day oral furosemide-equivalent loop diuretics, IV bolus furosemide at the same dose as oral loop diuretic dose). Outcomes were length of hospital stay, diuretic response (urine output achieved within 48 hours of admission per 40 mg furosemide-equivalent diuretics dose), and 60-day all-cause mortality.

Results

Median amount of first IV bolus furosemide dose were 10, 20, and 40 mg for lower, standard, and higher dose groups, respectively. After adjustment for other covariates, length of hospital stay was significantly longer by 2.6 days (p=0.018) in the lower dose group compared to the standard dose group, and there was no difference between the standard and high dose groups (p=0.221). Diuretic response within 48 hours of admission was significantly better in the lower dose group (beta coefficient: 244 mL, p=0.025) and significantly worse in the higher dose group (beta coefficient: - 1098 mL, p<0.001) compared to the standard dose group after adjustment for covariates. During 60 days of admission, 91 deaths were observed, and 60-day mortality was significantly higher in the higher dose group (HR: 2.80, 95% CI: 1.49–5.26, p=0.001), but not in the lower dose group (HR: 1.18, 95% CI: 0.67–2.08, p=0.571) compared to the standard dose group after adjustment for other prognostic factors.

Conclusion

Treatment with the recommended initial bolus of IV furosemide is associated with a shorter hospital stay compared to lower dose regimen and better diuretic response and better 60-day survival compared to higher dose regimen in patients with AHF.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

428In-hospital coronary angiography is associated with increased evidence based medications and better survival in patients hospitalized with acute heart failure - results from REALITY-AHF

Background

Coronary artery disease is a major cause of heart failure (HF). Urgent coronary angiography (CAG) is recommended for patients with acute HF (AHF) complicated with acute coronary syndrome (ACS); however, clinical usefulness of in-hospital CAG in AHF patients without ACS remains unknown.

Purpose

To investigate the association between in-hospital CAG and all-cause mortality at 1-year after hospital discharge and effects of medications at discharge on this association.

Methods

From the REALITY-AHF study, 1344 patients hospitalized with AHF were enrolled in this study and followed up for 1-year after hospital discharge.

Results

In-hospital CAG was undergone in 511 patients (38%). CAG group had a significantly lower 1-year mortality compared with non-CAG group (unadjusted hazard ratio [HR]; 0.30, 95%-confidence interval [CI] 0.21–0.43, P<0.001, after adjustment for MAGGIC score; HR 0.45, 95%-CI 0.29–0.70, P<0.001, in propensity-score matched 296 pairs; HR 0.60, 95%-CI 0.37–0.98, P=0.04). At discharge, aspirin, statins and beta blockers were prescribed more in CAG group compared with non-CAG group (aspirin 46% versus 30%, P<0.001, statins 51% versus 35%, P<0.001, and beta blockers 76% versus 65%, P=0.007). The prescription of aspirin or statins at discharge was associated with a better 1-year survival in patients with multivessel disease (P<0.001), but not in patients without significant stenosis or single vessel disease (P=0.95) (Figure).

CAG results, medications and mortality

Conclusions

In patients hospitalized with AHF, in-hospital CAG was associated with increased evidence based medications at discharge and a better long-term survival. Aspirin and statins at discharge might improve outcomes in AHF patients with multivessel disease.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

Abstract P3-10-23: Changes in the expression of HER2 and other genes in HER2-positive metastatic breast cancer induced by treatment with ado-trastuzumab emtansine and/or pertuzumab/trastuzumab

Background: Although tremendous progress has been achieved with targeted therapy for HER2-positive (HER2+) metastatic breast cancer, most advanced tumors eventually develop resistance. Improving our understanding of mechanisms of resistance to anti-HER2 therapy is needed to develop new therapeutic approaches. The purpose of this study was to identify the mechanisms of resistance to treatment with ado-trastuzumab emtansine (T-DM1) and/or taxane/pertuzumab/trastuzumab (TPH).

Methods: In our preclinical analysis, HER2+ cell lines resistant to treatment with T-DM1 (n=5), and pertuzumab/trastuzumab (n=3) were generated. HER2 expression in the original and resistant cell lines was compared using Western blot, and HER2 gene amplification was compared in them using fluorescence in situ hybridization (FISH) and a Droplet Digital Polymerase Chain Reaction HER2 copy-number-validation assay. In our clinical analysis, nine patients with HER2+ metastatic breast cancer who had progressed on T-DM1 and/or TPH were enrolled. Patients underwent biopsies following treatment with T-DM1 and/or TPH. Targeted next-generation sequencing was performed using the FoundationOne® assay (Foundation Medicine, Inc.) to identify gene alterations. Also, the HER2 expression before and after the therapy was compared using immunohistochemistry and/or FISH.

Results: In preclinical analysis, HER2 expression/amplification by Western blot and gene copy-number analysis was significantly decreased in T-DM1–resistant cell lines (four of five cell lines; P &lt; 0.01) but not in pertuzumab/trastuzumab-resistant cell lines (none of three cell lines). In clinical analysis, the patients' median age was 54 years (range, 45-77 years), and five patients (56%) were ER+. Five patients (56%) received first-line anti-HER2 therapy, and four patients (44%) received two lines of anti-HER2 therapy prior to enrollment. We observed loss of HER2 expression in four of nine patients (44%) after undergoing anti-HER2 therapy. After receiving TPH, one of eight patients (13%) lost HER2 positivity according to FISH. In contrast, after T-DM1, three of four tested patients (75%) lost HER2 amplification by FISH. As for next-generation sequencing, we analyzed seven samples: three after treatment with TPH and four after treatment with T-DM1. In four of these samples (57%), we observed loss of HER2 amplification: one after treatment with TPH and three after treatment with T-DM1. TP53 mutations were seen in all patients. Additionally, we observed TOP2A and MCL1 amplification in two patients with ERBB2 amplificationand AKT1 amplification in one patient with ERBB2 amplification loss.

Conclusions: We show for the first time that T-DM1–resistant breast cancer cells lose HER2 expression and amplification. Additionally, we observed loss of HER2 expression in patient samples following treatment with HER2 targeted therapy. Further study of resistant tumor samples is required to understand the impact of HER2 loss on outcomes. For the time being, repeating biopsy analysis of a metastatic site after treatment with T-DM1 to determine the HER2 expression status is reasonable, and it may increase the efficacy of future anti-HER2 therapy.

Citation Format: Kida K, Lee J, Liu H, Lim B, Murthy RK, Sahin AA, Tripathy D, Ueno NT. Changes in the expression of HER2 and other genes in HER2-positive metastatic breast cancer induced by treatment with ado-trastuzumab emtansine and/or pertuzumab/trastuzumab [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 P3-10-23.

Abstract P5-05-04: Myc as a poor prognostic marker for ER+ inflammatory breast cancer (IBC): Quantitative estrogen receptor (ER) expression analysis and gene expression analysis in ER+ IBC vs non-IBC

Background

Estrogen receptor-positive (ER+) primary inflammatory breast cancer (IBC) has a poorer prognosis than ER+ primary non-IBC. Our objective was to determine the association between ER positivity and survival outcome in order to elucidate the biological reason that ER+ IBC is more aggressive than non-IBC.

Methods

We retrospectively determined the relationship between ER expression by immunohistochemistry staining and neoadjuvant chemotherapy response as well as survival outcome for 189 patients with ER+ and HER2-negative (HER2-) IBC and 896 case-matched patients with stage III non-IBC seen at MD Anderson Cancer Center between January 1989 and April 2015. We performed gene expression (GE) analysis for 39 patients with ER+/HER2- IBC and 40 patients with non-IBC to detect genes that are specifically overexpressed in IBC. Logistic regression and Cox proportional hazards model were used to determine the predictive and prognostic value of percentages of cells positive for ER and progesterone receptor (PR) among the patients with ER+/HER2- IBC and non-IBC. Recursive partitioning analysis (RPA) was used to determine the optimal cutoff points for ER% and progesterone receptor (PR) % that maximized differences in survival. The identified cutoff points were tested in an external cohort of 192 ER+/HER2- IBC patients from Institut Paoli-Calmettes in France.

Results

The median values for ER% for IBC and non-IBC were 85 (range, 1-100) and 90 (range, 1-100), respectively. The logistic regression model demonstrated a lack of a relationship of ER% with pathological complete response rate to neoadjuvant chemotherapy both in IBC (P=0.29) and non-IBC (P=0.14). Expression of ER was significantly associated with distant disease-free survival (DDFS); hazard ratio (HR), 0.56 [95% CI, 0.37-0.83] per 50% increase in ER%; P&lt;0.05). Also, ER% was significantly associated with overall survival (OS) (HR, 0.40 [95% CI, 0.25-0.63] per 50% increase in ER%; P&lt;0.05). RPA showed that 91.5% and 9.0% were the optimal cutoff points for ER% and PR%, respectively, for DDFS and overall survival in IBC patients. However, the cutoff points could not be validated in the French external cohort. In the GE study, 84 genes were detected as significantly distinguishing ER+ IBC from non-IBC. Among the top 15 canonical pathways shown by IPA, the ERK/MAPK signaling pathway, PDGF pathway, insulin receptor signaling pathway, and IL-7 signaling pathway were associated with the ER signaling pathway. MYC upregulation was observed in three of these four pathways. Indeed, ER+/HER- IBC had significantly higher MYC amplification compared to those with non-IBC (P&lt;0.05) and higher MYC level was associated with poor relapse free survival for IBC (HR, 1.85 [95% CI, 1.05-2.70], P&lt;0.05).

Conclusions

Increased ER positivity was significantly associated with improved survival in ER+/HER- IBC patients. ER+/HER- IBC had several activated pathways with MYC upregulation compared to non-IBC. MYC upregulation was associated with a poor survival outcome for ER+/HER- IBC. The results indicate that MYC is a key gene for understanding the aggressive biological behavior of ER+/HER- IBC.

Citation Format: Iwase T, Harano K, Masuda H, Kida K, Espinosa Fernandez JR, Hess KR, Wang Y, Woodward WA, Layman RM, Dirix L, Van Laere SJ, Bertucci F, Ueno NT. Myc as a poor prognostic marker for ER+ inflammatory breast cancer (IBC): Quantitative estrogen receptor (ER) expression analysis and gene expression analysis in ER+ IBC vs non-IBC [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 P5-05-04.

Breathing hydrogen sulfide prevents delayed paraplegia in mice

Delayed paraplegia complicates the recovery from spinal cord ischemia or traumatic spinal cord injury. While delayed motor neuron apoptosis is implicated in the pathogenesis, no effective treatment or preventive measures is available for delayed paraplegia. Hydrogen sulfide exerts anti-apoptotic effects. Here, we examined effects of hydrogen sulfide breathing on the recovery from transient spinal cord ischemia. Breathing hydrogen sulfide starting 23 h after reperfusion for 5 h prevented delayed paraplegia after 5 min of spinal cord ischemia. Beneficial effects of hydrogen sulfide were mediated by upregulation of anti-apoptotic Bcl-XL and abolished by nitric oxide synthase 2 deficiency. S-nitrosylation of NFkB p65 subunit, which is induced by nitric oxide derived from nitric oxide synthase 2, facilitated subsequent sulfide-induced persulfidation of p65 and transcription of anti-apoptotic genes. These results uncover the molecular mechanism of the anti-apoptotic effects of sulfide based on the interaction between nitric oxide and sulfide. Exploitation of the anti-apoptotic effects of delayed hydrogen sulfide breathing may provide a new therapeutic approach for delayed paraplegia.

Abstract P6-12-26: The axonal damage marker, serum phosphorylated neurofilament heavy subunit, as a potential marker of chemotherapy-induced neuropathy

Background: Chemotherapy-induced neurologic disorders such as peripheral neuropathy and cognitive disturbance are clinically significant problems for cancer survivors, but their objective assessment methods have not been established. We previously reported in a cross-sectional study that the serum phosphorylated neurofilament heavy subunit (pNF-H), a biomarker of axonal damage, was increased in breast cancer patients treated with chemotherapy. The aim of this study is to temporally assess the neurological adverse events and evaluate the association of serum pNF-H level with cognitive functions and neuropathy following sequential chemotherapy.

Methods: Thirty-five breast cancer patients who received neoadjuvant or adjuvant chemotherapy were enrolled prospectively. They underwent brain MRI and cognitive function tests including Controlled Oral Word Association (COWA), Trail Making Test (TMT), and Hopkins Verbal Learning Test-Revised (HVLT-R) before chemotherapy (baseline), one month after completing sequential chemotherapy (post-phase) and more than six months after completing chemotherapy (late-phase). Serum pNF-H levels and questionnaires reporting peripheral neuropathy were measured at the three phases, and every 3 weeks during chemotherapy. Brain MRI volumetry was calculated by the automatic analysis software, BAAD® (Brain Anatomical Analysis using Dartel). The correlations among cognitive functions, brain volume, peripheral neuropathy and serum pNF-H levels were statistically analyzed.

Results: Patients' median age was 48 years (range 24-71). A decrease of more than 10% in cognitive function test (COWA) scores was seen in 10 cases (31%) at post-phase. A brain volume loss of more than 10% was seen in 5 cases (15%) at post-phase. The correlation between brain volume change and cognitive disturbance was not significant (p=0.45) and both changes were improved at late-phase. A peripheral neuropathy grade above CTCAE grade 2 was seen in 19 cases (54%). The neuropathy was significantly more severe in anthracycline followed by taxane regimen than taxane followed by anthracycline during chemotherapy (p=0.016), although this difference was not seen at the late-phase (p=0.08). An elevated serum pNF-H level at baseline was seen in only one case, and this case demonstrated the cognitive disturbance, brain volume loss, and peripheral neuropathy following chemotherapy. During chemotherapy, pNF-H was elevated in 24 patients (69%), with especially higher levels noted during the taxane regimen compared to the anthracycline regimen (p=0.019). In the cases treated with anthracycline followed by taxane, the taxane-phase elevation was especially significant (p=0.014). The maximum pNF-H level during taxane therapy was significantly correlated with peripheral neuropathy grade (p=0.002). At late-phase, the significant reduction of pNF-H level was seen in all cases.

Conclusions: Change of cognitive function, brain volume and peripheral neuropathy was observed following chemotherapy in breast cancer patients. This study suggests that the serum axonal damage marker, pNF-H, may reflect chemotherapy-induced neuropathy.

Citation Format: Kida K, Sumitani M, Ogata T, Kotake R, Natori A, Hashimoto J, Shimokawa T, Yamauchi H, Yamauchi T. The axonal damage marker, serum phosphorylated neurofilament heavy subunit, as a potential marker of chemotherapy-induced neuropathy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-26.

Abstract P6-07-03: Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival

Background: Cancer stem cells (CSC) are good sources of tumor initiation, heterogeneity, progression, and metastasis because of their unique characteristics. Several potential markers for CSCs have been suggested for breast cancer, including CD44+/CD24−/low, aldehyde dehydrogenase 1 (ALDH1), and epithelial cell adhesion molecule/epithelial-specific antigen. We previously reported that ALDH1 gene expression is related to aggressive phenotypes and poor prognosis in breast cancers. In this study, we conducted differential analysis of mRNA expression in ALDH1-positive breast cancer to identify genes associated with CSC. Next, we performed basic and clinical studies of one gene.

Methods: Messenger RNA was isolated from ALDH1-positive cells and ALDH1-negative cells in 5 ALDH1-positive breast cancers. Microarray analysis revealed that several genes were significantly associated with the ALDH1 gene. Among them, we examined a long non-coding RNA of H19 in this study. We evaluated the effect of H19 on CSCs using RNA interference and a sphere formation assay using two cell lines, HCC1937 and iCSCL10A cells. We also investigated H19 expression in 192 surgical specimens by in situ hybridization and analyzed the relationship between H19 expression and clinic pathological findings in breast cancer patients.

Results: Through in vitro experiments, we confirmed that suppression of H19 reduced sphere formation in both HCC1937 and iCSCL10A cells. Among surgical specimens, 48 samples (25%) expressed H19. We verified thatH19 positivity was significantly higher in ALDH1-positive cases than in ALDH1-negative cases (68% vs 9.7%, p &lt; 0.001). H19 was significantly highly expressed in triple-negative breast cancer (TNBC) (46%) compared with other subtypes: luminal (33%), luminal-HER2 (6%), and HER2-enriched subtype (15%). H19-positive patients showed significantly worse prognosis (5-year disease-free survival 75.8% vs 91.5%, p = 0.001 and 5-year overall survival 88.7% vs 97.7%, p = 0.002). The effect of H19 expression on prognosis was the most significant in TNBC compared to in other subtypes (5-year disease-free survival 63.6% vs 88.9%, p = 0.038).

Conclusions: H19 is clearly associated with CSCs and correlated with poor prognosis in breast cancer patients, particularly TNBC. Our future studies will investigate the role of H19 in maintaining the nature of CSCs and protein-coding genes associated with H19.

Citation Format: Shima H, Kida K, Yamada A, Sugae S, Narui K, Miyagi Y, Ryo A, Ichikawa Y, Ishikawa T, Endo I. Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-07-03.

Abstract P5-16-04: A randomized phase II neoadjuvant study comparing docetaxel and cyclophosphamide (TC) with 5-fluorouracil, epirubicin, and cyclophosphamide followed by docetaxel (FEC-D) for hormone receptor-negative breast cancer: The Kanagawa breast oncology group (KBOG) 1101 study

Purpose: This study aimed to evaluate response to neoadjuvant chemotherapy (NAC) for patients with hormone receptor-negative (HR-negative) breast cancer (BC) to identify subtypes that require anthracycline treatment.

Methods: In total, 103 patients with operable HR-negative BC were registered. They were randomely assigned to administration of 6 cycles of docetaxel (75mg/m2) and cyclophosphamide (600 mg/m2) (TC6) or 3 cycles of 5-fluorouracil (500 mg/m2), epirubicin (100mg/m2), and cyclophosphamide (500mg/m2) followed by 3 cycles of docetaxel (100mg/m2) (FEC-D). Cytokeratin (CK) 5/6 and EGFR expression were used to identify basal and non-basal triple-negative (TN) BC. The primary endpoint was pathological complete response (pCR); secondary endpoints were safety, breast-conserving surgery, disease-free survival, and overall survival. Predictive factors of pCR for each regimen were also evaluated.

Results:

The pCR rate was 36% for FEC-D and 25.5% for TC6, which did not differ significantly (P=0.265). When TN BC was subdivided into basal and non-basal subtypes, the pCR rate in the basal subtype was significantly lower for TC6 (13.6%) than for FEC-D (42.9%) (P=0.033), but did not significantly differ in the non-basal (TC6, 36.4%; FEC-D, 25.0%) and HER2-positive (TC6, 41.7%; FEC-D, 35.7%) cases.

The relative dose intensities of epirubicin and docetaxel in FEC-D and docetaxel in TC6 were 96.3±13.0%, 93.5±14.6%, and 93.9±16.3% (mean±SD), respectively. Occurrence of grade ≥2 adverse events was significant in FEC-D-treated patients. Poor appetite (P&lt;0.001), nausea (P&lt;0.001), vomiting (P&lt;0.001), dysgeusia (P=0.03), and fatigue (P=0.05) were significantly more common for FEC-D than TC6. Patients treated with FEC-D experienced significantly more febrile neutropenia and anemia (P=0.016 and 0.017, respectively).

The rates of breast-conserving surgery were 68.0 and 72.3% for FEC-D and TC6, respectively (P=0.641).

Patients achieved pCR had better DFS (log rank test, P = 0.287) and OS (log rank test, P = 0.069), though not significant. Patients treated with FEC-D had better DFS (log rank test, P = 0.107) and OS (log rank test, P = 0.159), though not significant. Among patients with TN BC, those treated with FEC-D had significantly better DFS (log rank test, P = 0.016) and OS (log rank test, P = 0.034) than treated with TC6.

Low ALDH1 expression and high topo IIα protein expression were strongly correlated with pCR in FEC-D, with odds ratios (ORs) of 4.33 [95% CI, 1.02–18.38] and 4.08 [0.97–17.2], respectively. ALDH1 was also associated with pCR in TC, OR=3.50 [0.84–14.6]. Other factors, including age, tumor size, nodal status, tumor grade, Ki67, p53, and TOP 2A status were not associated with pCR in either regimen.

Conclusions:We found that TC6 was less effective than FEC-D for treating HR-negative BC because it was insufficient for TNBC, particularly for basal BC. This suggests that anthracycline is more important than taxane for basal BC. Additionally, ALDH1 could be a marker for resistance to conventional chemotherapy.

Citation Format: Narui K, Ishikawa T, Shimizu D, Tanabe M, Sasaki T, Oba MS, Morita S, Nawata S, Kida K, Mogaki M, Doi T, Tsugawa K, Ogata H, Ota T, Kosaka Y, Sengoku N, Kuranami M, Saito Y, Suzuki Y, Suto A, Arioka H, Chishima T, Ichikawa Y, Endo I, Tokuda Y. A randomized phase II neoadjuvant study comparing docetaxel and cyclophosphamide (TC) with 5-fluorouracil, epirubicin, and cyclophosphamide followed by docetaxel (FEC-D) for hormone receptor-negative breast cancer: The Kanagawa breast oncology group (KBOG) 1101 study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-04.

Polymorphism in promoter region of growth hormone receptor is associated with potential production capacity of insulin-like growth factor-1 in pre-pubertal Holstein heifers

Insulin-like growth factor-1 (IGF-1) is one of the important factors for growth, milk production and reproductive functions and mainly released from the liver in response to growth hormone (GH) via GH receptor (GHR) in cattle. Recently, some single nucleotide polymorphisms (SNPs) were identified in the bovine GHR gene. Some GHR-SNPs were shown to be related to plasma IGF-1 concentration in cattle. Hence, the capacity to IGF-1 production in the liver might be affected by GHR-SNP and associated with performance in the future. This study examined whether GHR-SNP is associated with IGF-1 production in the liver of pre-pubertal heifers. In 71 Holstein calves, blood samples for genomic DNA extraction were obtained immediately after birth. To genotype the GHR-SNPs in the promoter region, polymerase chain reaction (PCR) products were digested with restriction enzyme NsiI (cutting sites: AA, AG and GG). All heifers at 4 months of age were intramuscularly injected with 0.4 mg oestradiol benzoate. Blood samples were obtained from the jugular vein just before (0 h) and 24 h after injection. The number of AA, AG and GG at the NsiI site was 0, 17 and 54 respectively. In AG and GG, plasma GH concentrations were higher pre-injection than 24 h post-injection (p < 0.01). Moreover, plasma GH concentrations in AG post-injection were higher than in GG (p < 0.05). In contrast, the GG genotype exhibited higher plasma IGF-1 concentrations in pre-injection than post-injection (p < 0.01), although oestradiol did not change IGF-1 concentration in the AG genotype. We conclude that the GG polymorphism in the promoter region of GHR is associated with a higher potential capacity of IGF-1 production in the liver of cattle.

Thiamine as a neuroprotective agent after cardiac arrest

AIMS

Reduction of pyruvate dehydrogenase (PDH) activity in the brain is associated with neurological deficits in animals resuscitated from cardiac arrest. Thiamine is an essential co-factor of PDH. The objective of this study was to examine whether administration of thiamine improves outcomes after cardiac arrest in mice. Secondarily, we aimed to characterize the impact of cardiac arrest on PDH activity in mice and humans.

METHODS

Animal study: Adult mice were subjected to cardiac arrest whereupon cardiopulmonary resuscitation was performed. Thiamine or vehicle was administered 2min before resuscitation and daily thereafter. Mortality, neurological outcome, and metabolic markers were evaluated. Human study: In a convenience sample of post-cardiac arrest patients, we measured serial PDH activity from peripheral blood mononuclear cells and compared them to healthy controls.

RESULTS

Animal study: Mice treated with thiamine had increased 10-day survival (48% versus 17%, P<0.01) and improved neurological function when compared to vehicle-treated mice. In addition, thiamine markedly improved histological brain injury compared to vehicle. The beneficial effects of thiamine were accompanied by improved oxygen consumption in mitochondria, restored thiamine pyrophosphate levels, and increased PDH activity in the brain at 10 days. Human study: Post-cardiac arrest patients had lower PDH activity in mononuclear cells than did healthy volunteers (estimated difference: -5.8O.D./min/mg protein, P<0.001).

CONCLUSIONS

The provision of thiamine after cardiac arrest improved neurological outcome and 10-day survival in mice. PDH activity was markedly depressed in post-cardiac arrest patients suggesting that this pathway may represent a therapeutic target.

BRCAness is beneficial for indicating triple negative breast cancer patients resistant to taxane

AIM

Triple negative breast cancer (TNBC) is a heterogeneous disease and is associated with the cancer stem cell (CSC), basal-like, and BRCA1 function deficient (BRCAness) subtypes. We examined these 3 subtypes in TNBC and compared their chemosensitivity against anthracycline or taxane with a special attention to BRCAness.

METHODS

Sixty-six TNBC cases were obtained from a randomized phase II trial comparing TCx6 (TC6) with FEC-Docetaxel (FEC-D) as neoadjuvant chemotherapy. The core needle specimens before chemotherapy were used for subtyping. The basal-like and CSC subtypes were identified by immunohistochemistry; CK5/6 and EGFR staining for the basal-like subtype and ALDH1 staining for the CSC subtype. The BRCAness subtype was examined by Multiplex Ligation-dependent Probe Amplification (MLPA). Correlations between subgroups and pCR rates according to each regimen and subtype were examined.

RESULTS

The basal-like and BRCAness subtypes were significantly associated (p = 0.010) with the other subtypes, but not the CSC subtype. The pCR rates were higher with FEC-D than with TC6 in the basal-like (54.5% vs 14.3%, p = 0.081) and BRCAness (56.2% vs 16.7%, p = 0.030) subtypes. Both were not effective in the CSC subtype (18.2% vs 11.8%, p = 1.00).

CONCLUSION

BRCAness identified by MLPA was practically useful for treatment selection for avoiding taxane. ALDH1 may be considered as a marker for the CSC subtype requiring novel agents.

S-Nitrosylation of Calcium-Handling Proteins in Cardiac Adrenergic Signaling and Hypertrophy

RATIONALE

The regulation of calcium (Ca(2+)) homeostasis by β-adrenergic receptor (βAR) activation provides the essential underpinnings of sympathetic regulation of myocardial function, as well as a basis for understanding molecular events that result in hypertrophic signaling and heart failure. Sympathetic stimulation of the βAR not only induces protein phosphorylation but also activates nitric oxide-dependent signaling, which modulates cardiac contractility. Nonetheless, the role of nitric oxide in βAR-dependent regulation of Ca(2+) handling has not yet been explicated fully.

OBJECTIVE

To elucidate the role of protein S-nitrosylation, a major transducer of nitric oxide bioactivity, on βAR-dependent alterations in cardiomyocyte Ca(2+) handling and hypertrophy.

METHODS AND RESULTS

Using transgenic mice to titrate the levels of protein S-nitrosylation, we uncovered major roles for protein S-nitrosylation, in general, and for phospholamban and cardiac troponin C S-nitrosylation, in particular, in βAR-dependent regulation of Ca(2+) homeostasis. Notably, S-nitrosylation of phospholamban consequent upon βAR stimulation is necessary for the inhibitory pentamerization of phospholamban, which activates sarcoplasmic reticulum Ca(2+)-ATPase and increases cytosolic Ca(2+) transients. Coincident S-nitrosylation of cardiac troponin C decreases myocardial sensitivity to Ca(2+). During chronic adrenergic stimulation, global reductions in cellular S-nitrosylation mitigate hypertrophic signaling resulting from Ca(2+) overload.

CONCLUSIONS

S-Nitrosylation operates in concert with phosphorylation to regulate many cardiac Ca(2+)-handling proteins, including phospholamban and cardiac troponin C, thereby playing an essential and previously unrecognized role in cardiac Ca(2+) homeostasis. Manipulation of the S-nitrosylation level may prove therapeutic in heart failure.

A prospective feasibility study of sentinel node biopsy by modified Indigocarmine blue dye methods after neoadjuvant chemotherapy for breast cancer

BACKGROUND

Although sentinel lymph node biopsy (SLNB) is a standard staging method for assessing nodal status of breast cancer patients, SLNB after neoadjuvant chemotherapy (NAC) remains controversial. The aim of this study was to validate the practicality and accuracy of SLNB by our modified Indigocarmine blue dye methods following NAC.

METHODS

One hundred consecutive cases with breast cancers treated by NAC were enrolled in this study. After NAC, all patients underwent SLNB performed by our modified Indigocarmine blue dye methods without radioisotope, followed by back-up axillary lymph node dissection (ALND).

RESULTS

Sentinel nodes (SNs) were identified in 94 cases (identification rate, 94%); the accuracy was 94.7% (89/94 cases); and the false negative rate (FNR) 13.5% (5/37 cases). For cases with vs. without clinically evident metastatic nodes before NAC, the identification rate was 92.4% (61/66 cases) vs. 97.1% (33/34 cases); the accuracy 91.8% (56/61 cases) vs. 97.0% (32/33 cases) and the FNR 16.1% (5/31 cases) vs. 0% (0/6 case), respectively. There were six patients without identified SNs, three of them had metastatic nodes. False negatives occurred in five cases; in four, fewer than two sentinel nodes had been removed.

CONCLUSION

Following NAC, the accuracy of SLNB by modified Indigocarmine blue dye methods is adequate compared with other tracers. In patients in whom no SNs have been identified, lymphatic metastasis is likely and therefore ALND is recommended. For patients with cN0 prior to NAC, SLNB by modified Indigocarmine blue dye methods is clinically feasible, though controversial for patients with positive nodes.

Hydrogen Sulfide and Neuroinflammation

The innate and adaptive immune system plays an important role in diverse forms of central nervous system (CNS) pathologies including neurodegenerative diseases and peripheral nerve injury. Evidence for an innate inflammatory response in Alzheimer's disease (AD) was described 20 years ago, and subsequent studies have documented roles of inflammation in Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and a growing number of other CNS pathologies. Although inflammation may not be the initiating factor for neurodegenerative pathologies, experimental data suggests that persistent inflammatory responses involving microglia and astrocytes, as well as blood monocyte-derived macrophages, clearly contribute to disease progression. High levels of hydrogen sulfide exert toxic effects to CNS. On the other hand, low and physiological levels of H2S may have beneficial effects on number of tissues including CNS. For example, a number of studies have reported that H2S exerts anti-inflammatory and anti-apoptotic effects in CNS. In this chapter, studies related to the role of H2S in neuroinflammation and neurodegeneration will be reviewed and discussed. In particular, we will focus on the role of H2S in neuroinflammation associated with PD.

Inhaled hydrogen sulfide prevents neuropathic pain after peripheral nerve injury in mice

Increasing evidence suggests that the pathogenesis of neuropathic pain is mediated through activation of microglia in the spinal cord. Hydrogen sulfide attenuates microglial activation and central nervous system inflammation; however, the role of hydrogen sulfide in neuropathic pain is unclear. In this study, we examined the effects of hydrogen sulfide breathing on neuropathic pain in mice. C57BL/6J mice were subjected to chronic constriction injury (CCI) of the sciatic nerve. After CCI, mice breathed air alone or air mixed with hydrogen sulfide at 40 ppm for 8 h on 7 consecutive days. The expression levels of inflammatory cytokines including interleukin 6 (IL-6) were measured in the spinal cord. Effects of hydrogen sulfide on IL-6-induced activation of microglia were examined in primary rat microglia. Mice that breathed air alone exhibited the neuropathic pain behavior including mechanical allodynia and thermal hyperalgesia and increased mRNA levels of IL-6 and chemokine CC motif ligand 2 (CCL2) after CCI. Inhaled hydrogen sulfide prevented the neuropathic pain behavior and attenuated the upregulation of inflammatory cytokines. Sodium sulfide inhibited IL-6-induced activation of primary microglia. These results suggest that inhaled hydrogen sulfide prevents the development of neuropathic pain in mice possibly via inhibition of the activation of microglia in the spinal cord.

Outcomes of immediate perforator flap reconstruction after skin-sparing mastectomy following neoadjuvant chemotherapy

BACKGROUND

The impact of neoadjuvant chemotherapy (NACT) on immediate free flap breast reconstruction remains controversial. Furthermore, the oncological outcomes of immediate free flap breast reconstruction after skin-sparing mastectomy (SSM) following NACT remain unclear. This study aimed to investigate the surgical complications and oncological outcomes of immediate perforator flap reconstruction after SSM following NACT.

METHODS

A total of 201 consecutive patients with indications for immediate perforator flap reconstruction after SSM were included between 2004 and 2012. Surgical and oncological outcomes were compared between patients with and without NACT.

RESULTS

There were 38 patients in the NACT group and 163 in the non-NACT control group. The median age of the NACT group was 39.5 years, which was significantly younger than the control group (43.0 years; P < 0.05). Patients in the NACT group also had more advanced and aggressive disease (P < 0.05). There was no significant difference in the frequency of surgical complications between the groups, no difference in the type of complications, and no significant difference in the frequencies of major and minor complications. No patients in the NACT group had delayed adjuvant therapy. Eight patients (4%) developed recurrences, with a median follow-up time of 3.0 years. Local recurrences occurred in three control patients but no patients in the NACT group.

CONCLUSION

NACT does not affect short-term or interim outcomes after immediate perforator flap reconstruction and may thus represent a safe and practical treatment option for the multidisciplinary treatment of breast cancer.

Imaging findings of necrotizing sialometaplasia of the parotid gland: case report and literature review

Although necrotizing sialometaplasia (NS) of the parotid gland is rare and occasionally presents as a lesion that mimics a malignant tumour, imaging findings in cases of NS have been rarely reported. We describe here a case of NS in which there was an increasing lesion manifesting overnight on the parotid gland in an 83-year-old male. We also investigated the use of pre-operative imaging based on previous reports and discuss the importance of these images in helping to guard against overzealous treatment. It is critically important to closely examine whether there are aspects of NS, such as the present case, in pre-operative MRI findings that can be useful in proper diagnosis and treatment.

Abstract P6-06-27: Expression of ATP-binding cassette transporter C1 (ABCC1) and activated sphingosine kinase 1 in breast cancer are associated with significantly shorter disease free survival

Background and specific objectives: ATP-binding cassette (ABC) transporters are known to be multidrug resistance proteins that efflux various compounds out of cells including chemotherapeutic agents. A number of clinical trails have been conducted targeting ABCB1: however, none showed beneficial effects. The pleiotropic bioactive lipid mediator sphingosine-1-phosphate (S1P), which is generated by sphingosine kinase 1 (SphK1) inside breast cancer cells and exerts its functions by binding to its specific cell surface G-protein coupled receptors (S1PR1-5) after being exported, is now known as a key regulatory molecule in breast cancer progression. We have previously demonstrated that ABCC1 and ABCG2, but not ABCB1 export S1P out of MCF7 human breast cancer cells. We hypothesized that ABCC1 expression in the presence of S1P produced by activated SphK1 in human breast cancer is associated with poor prognosis.

Methods: We constructed a tissue microarray with 281 breast tumors from patients, and analyzed expressions of ABCB1, ABCC1, and ABCG2, activated SphK1 (pSphK1), and S1P receptor-1 (S1PR1) immunohistochemically. Breast cancer subtypes were determined by immunohistochemistry of ER, PR, and HER2. Protein expressions were correlated to clinicopathological characteristics, clinical follow-up, and pathological complete response to neoadjuvant chemotherapy. For in vitro experiments, MCF7 human breast cancer cells were transfected with ABCB1 or ABCC1 and stimulated with estradiol. Cell proliferation was analyzed by WST-8 assay.

Results: The tissue microarray was comprised of 191 luminal A (68.0%), 17 luminal B (6.0%), 27 HER2 (9.6%), and 46 triple-negative (16.4%) tumors. Activated SphK1 was highly expressed in the patients with lymph node metastasis (40.1% vs 27.3%, P = 0.037) and the pSphK1 high expression group had significantly shorter disease free survival (DFS) (P = 0.05). Eighty percent of the patients expressed S1PR1; however, there were no significant differences in prognosis. On the other hand, ABCC1 expression was associated with significantly shorter DFS (P = 0.027). ABCC1 and ABCG2, but not ABCB1, were significantly higher and more frequently expressed in aggressive subtypes. Patients with tumors expressing both pSphK1 and ABCC1 had significantly shorter DFS (P = 0.002), while patients expressing both ABCB1 and pSphK1 did not. Overexpression of ABCC1 in MCF7 cells not only increased S1P secretion, it significantly increased estradiol-dependent proliferation, compared to MCF7 cells transfected with control vector or ABCB1 (P = 0.010 and P = 0.027, respectively).

Conclusions: We have shown that ABCC1 and ABCG2 are highly expressed in aggressive breast cancer subtypes, and that co-expression of pSphK1 and ABCC1 in the tumors is associated with poor prognosis. Our results suggest that inside-out signaling of S1P via ABCC1 may play a significant role in the course of human breast cancer progression.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-27.

Abstract P3-14-08: A randomized phase II trial comparing docetaxel plus cyclophosphamide with epirubicin plus cyclophosphamide followed by docetaxel as neoadjuvant chemotherapy for hormone receptor-negative breast cancer. Kanagawa breast oncology group (KBOG) 1101 study

Background: Taxane-based regimens have been developed and used widely to treat breast cancer. It has therefore become important to identify subgroups of patients in which anthracyclines are indispensable. Pathological response to neoadjuvant chemotherapy (NAC) predicts prognosis in hormone-negative subtypes. We therefore initiated a randomized phase II NAC study to compare a taxane with and without an anthracycline in these breast-cancer subtypes.

Aim: To determine the safety and activity of six cycles of docetaxel and cyclophosphamide (TC6) compared with 5-fluorouracil, epirubicin, and cyclophosphamide followed by docetaxel (FEC-D), and to examine the predictive factors for each regimen.

Methods: Eligibility criteria were operable hormone-receptor-negative breast cancer, age younger than 75 years and ECOG PS0-1. According to HER2 status, patients were randomly assigned to TC (75/600 mg/m2) every 3 weeks X 6 or FEC (500/100/500 mg/m2) every 3 weeks X 3 followed by D (100 mg/m2) every 3 weeks X 3. The primary endpoint was the rate of pathological complete response (pCR; grade 3). Triple-negative (TN) breast cancer was subdivided by cytokeratin 5/6 and epidermal growth factor receptor into basal- and non-basal subtypes. Secondary endpoints were safety, breast-conserving surgery, disease-free survival, overall survival, and predictive factors: Ki-67, p53, aldehyde dehydrogenase (ALDH) 1 and topoisomerase 2A by both immunohistochemistry and fluorescence in situ hybridization for each regimen.

Results: Ninety-seven of 103 patients were analyzed successfully (50 for FEC-D and 47 for TC6). Significantly more severe adverse events (grade 2) were observed in FEC-D-treated patients (poor appetite, nausea and vomiting: p = 0.001; febrile neutropenia: p = 0.016). The pCR rate tended to be higher in FEC-D-treated patients compared with TC6-treated patients (pCR: 36.0 vs. 25.5%, n.s.). FEC-D treatment was significantly more effective than TC6 in basal-type (p = 0.033) but not in non-basal and HER2 subtypes. ALDH1 was associated with resistance to both regimens (FEC-D: p = 0.047, TC6: p = 0.085)

Conclusions: TC6 was safer, but not more effective than FEC-D. TC6 was significantly less active than FEC-D in basal subtype, and equivalent to FEC-D in HER2 and non-basal subtypes. Concurrent use of trastuzumab with TC could thus represent a reasonable option for NAC in HER2-subtype patients. ALDH1 could provide a marker for novel strategies such as stem cell-based therapies for breast cancer. Analyses on pathological factors in surgical specimens after NAC will be presented at the meeting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-08.